Office & Outpatient Coding Tools

CHIEF COMPLAINT: [PATIENT CONCERN] HISTORY OF PRESENT ILLNESS: [PATIENT NAME] is a [AGE]-year-old [GENDER] who presents with [CHIEF COMPLAINT]. [DETAILED HPI WITH 4+ ELEMENTS] REVIEW OF SYSTEMS: [PERTINENT POSITIVES AND NEGATIVES] PAST MEDICAL HISTORY: [RELEVANT PMH] MEDICATIONS: [CURRENT MEDICATIONS] ALLERGIES: [ALLERGIES OR NKDA] PHYSICAL EXAMINATION: Vital Signs: [VS] General: [GENERAL APPEARANCE] [PERTINENT PHYSICAL EXAM FINDINGS - 2+ ORGAN SYSTEMS] ASSESSMENT AND PLAN: 1. [DIAGNOSIS 1] - [ICD-10 CODE] - Management: [PLAN] 2. [DIAGNOSIS 2] - [ICD-10 CODE] - Management: [PLAN] MDM Elements: - Problems: [1 chronic with exacerbation OR 2 stable chronic OR 1 undiagnosed new problem] - Data: [Review of tests/notes OR independent interpretation] - Risk: [Moderate risk - prescription drug management] Total time: [TIME] minutes

CHIEF COMPLAINT: [PATIENT CONCERN] HISTORY OF PRESENT ILLNESS: [PATIENT NAME] is a [AGE]-year-old [GENDER] who presents with [CHIEF COMPLAINT]. [DETAILED HPI WITH 4+ ELEMENTS] REVIEW OF SYSTEMS: [PERTINENT POSITIVES AND NEGATIVES] PAST MEDICAL HISTORY: [RELEVANT PMH] MEDICATIONS: [CURRENT MEDICATIONS] ALLERGIES: [ALLERGIES OR NKDA] PHYSICAL EXAMINATION: Vital Signs: [VS] General: [GENERAL APPEARANCE] [PERTINENT PHYSICAL EXAM FINDINGS - 2+ ORGAN SYSTEMS] ASSESSMENT AND PLAN: 1. [DIAGNOSIS 1] - [ICD-10 CODE] - Management: [PLAN] 2. [DIAGNOSIS 2] - [ICD-10 CODE] - Management: [PLAN] MDM Elements: - Problems: [1+ chronic with severe exacerbation OR acute illness posing threat] - Data: [Independent interpretation AND discussion with external physician] - Risk: [High risk - drug requiring intensive monitoring OR emergency surgery decision] Discussion: [DETAILED DISCUSSION OF MANAGEMENT OPTIONS AND RISKS] Total time: [TIME] minutes

TRANSITIONAL CARE MANAGEMENT NOTE Patient: [PATIENT NAME] Date of Discharge: [DISCHARGE DATE] from [HOSPITAL NAME] Date of Initial Contact: [CONTACT DATE] (within 2 business days) Date of Face-to-Face Visit: [VISIT DATE] (within 7 calendar days) DISCHARGE DIAGNOSES: 1. [DIAGNOSIS] - [ICD-10] 2. [DIAGNOSIS] - [ICD-10] CHIEF COMPLAINT: Post-discharge follow-up INTERVAL HISTORY: Patient was discharged on [DATE] following [REASON FOR ADMISSION]. [REVIEW HOSPITAL COURSE AND CURRENT STATUS] MEDICATIONS RECONCILED: [LIST ALL MEDICATIONS WITH CHANGES NOTED] PHYSICAL EXAMINATION: [FOCUSED EXAM RELATED TO DISCHARGE DIAGNOSES] ASSESSMENT AND PLAN: [ADDRESS EACH DISCHARGE DIAGNOSIS AND ONGOING CARE PLAN] TCM SERVICES PROVIDED: - Communication with patient/caregiver within 2 business days of discharge ✓ - Medical decision making of moderate complexity ✓ - Face-to-face visit within 7 calendar days ✓ CPT: 99496 (wRVU 4.29)

CHIEF COMPLAINT: [PATIENT CONCERN] HISTORY OF PRESENT ILLNESS: [DETAILED HPI] REVIEW OF SYSTEMS: [ROS] PHYSICAL EXAMINATION: [FOCUSED EXAM] ASSESSMENT AND PLAN: 1. [PROCEDURE DIAGNOSIS] - [ICD-10] - Performed: [PROCEDURE NAME] - CPT [CODE] 2. [SEPARATE E/M DIAGNOSIS] - [ICD-10] - This is a SEPARATE and DISTINCT issue from the procedure - [DETAILED MANAGEMENT PLAN FOR E/M ISSUE] - This evaluation required significant additional work beyond what is normally included with the procedure PROCEDURE NOTE: [SEPARATE DETAILED PROCEDURE NOTE] MODIFIER -25 JUSTIFICATION: The evaluation and management service was significant and separately identifiable from the procedure. The E/M addressed [DISTINCT DIAGNOSIS/CONCERN] which required separate decision-making beyond the care normally provided with [PROCEDURE]. CPT Codes: - [PROCEDURE CPT] - [E/M CODE]-25