Hi V Norman
They should be aware or able to verify patient, mode of treatment listed is video, phone call or face to face, add minutes talk with patient, get list of current vs past medical histories and last time inpatient & problem. Review meds but also about current visit of the assessment or dx then describe what is going on/or treatment. Also if referred by anther doc list his or her name too. List current complaint or if follow up on what issue.
If pt disabled or in chronic pain...list the medical reason (cardiac, muscle, depression, HTN, CHKD,HIV, ,G31 or F02, R54 ,back problems. Etc) List chronic problems and meds too. Try not to use unspecified dx use detailed dx in documentation.
If pt blind, hard of hearing, committed suicide once, amputation, autistic, in wheelchair, has pacemaker, crippled Etc..list this data too
Cannot bill Transitional case mgmnt. and Chronic care management at same time either.
I hope this data helps you
Lady T