Here are key revisions to documentation guidelines.
ED reimbursement experts say the new documentation guidelines proposed by the Health Care Financing Administration will be easier to comply with. For a comprehensive history, only five organ systems are required to be reviewed, not 10. Instead of organ systems, the number of physical exam elements now includes individual components of those systems. It will be easier to identify the level of history if the patient is unable to give an adequate history.
D014487:Centers for Medicare and Medicaid Services, U.S.; D004282:Documentation / Q000592:standards; D017723:Drug Utilization Review; D004636:Emergency Service, Hospital / Q000191:economics / Q000592:standards*; D005568:Forms and Records Control / Q000592:standards*; D017408:Guidelines as Topic; D007344:Insurance Claim Reporting / Q000592:standards*; D008487:Medical History Taking; D010808:Physical Examination; D010818:Practice Patterns, Physicians'; D014481:United States