documentation requirement

  1. M

    Wiki 95117 / Allergy injections - documentation requirement

    Greetings all :) Our practice is considering adding administration of allergy immunotherapy injections to our list of services (CPT 95115/ 95117). The patients will bring the substance vials from their allergist. Other than the supporting Dx, what documentation MUST the Note include? It is a...
  2. P

    Wiki Remote Patient & Therapy Monitoring

    I'm looking to see if someone can provide me either a simple note example or a documentation template for Remote Patient Monitoring (CPT 99453-99458), or Remote Therapy Monitoring (CPT 98975-98981). We have provided the providers the information that needs to be included; however, they are...
    • PBJones0107
    • Thread
    • documentation requirement e/m questions remote remote patient monitoring remote theraputic monitoring
    • Replies: 1
    • Forum: E/M
  3. A

    Wiki Does anyone have good documentation formats for ophthalmologist outpatient procedure?

    Hi all, Could anyone help me with good documentation formats for ophthalmologist outpatient procedure such as blepharotomy, drainage of abscess, eyelid, retrobulbar injection etc. :)
  4. E

    Wiki PHYSICIAN ORDER REQUIREMENTS

    Does anyone have a CMS link to physician order requirements in the outpatient facility settings? (Think injection, infusions, etc). I am having a hard time presenting anything with specific details; i.e. written diagnosis. Thanks!
  5. T

    Wiki Required documentation for billable services - Nurse Visits

    Hello, I am looking for guidance on required documentation. Are SOAP notes and/or EHR master notes required for lab only or vaccine only visits (not with a provider)? Examples: Nurses Visit: Vaccine only, Nurses Visit: Covid vaccine only, Nurses Visit: Lab work (G0328, 82962, etc.) I appreciate...
  6. G

    Wiki Documentation Requirements for Labs

    I had a question regarding documentation requirements for independent laboratories. After talking with a lab they said they only have access to physician orders/ requisitions and the lab results. I know they say they just complete tests that are requested, but is that all they need? If they...
  7. A

    Wiki Documentation for Arthrocentesis and Injections

    I am trying to find a break down of the required elements of documenting arthrocentesis/injection. Clarification on what I am looking for to ensure the injection is documented correctly. Something I can use to show providers what is missing. I have the gist, but having a detailed break down...
    • amylynnwilson
    • Thread
    • arthrocentesis documentation requirement injection orthopaedics
    • Replies: 2
    • Forum: Orthopaedics
  8. E

    Wiki Documentation Requirement for Assistant at C/S

    Hello! Our practice has two MD's and two CNM's. Often, the CNM's will assist during Cesarean Deliveries. The provider will list the assistant CNM in the heading of the operative report simply as: Assistant: CNM's name The remainder of the operative report does not mention the CNM again. I am in...
    • ELBrock
    • Thread
    • assist at cesarean cesarean delivery assistant cnm assist documentation requirement modifier as
    • Replies: 9
    • Forum: OB/GYN
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