Detailed Documentation Guidelines
1. Rapid flu/strep tests - Order rapid flu/strep tests like you order regular under Lab
Reports. Once you add them, their respective CPT codes will also be added
automatically.
2. Finger-stick glucose test - Rarely, we will order a finger-stick glucose test to check a
patient’s blood sugar levels during the visit. Do not add the inhouse Glucose finger-stick
test that is under Lab Reports—that test currently has the wrong CPT code associated
with it. Instead, simply write “Point-of-care glucose: (result)” in the plan and add the
CPT code: 82947
3. New pt/existing pt - Check to see if a patient is new or not and ensure the correct billing
codes are used—remember that a patient is considered new if they haven’t been seen
by us in 3 years and/or have ONLY been seen by specialty (derm/ortho) in the past.
Please contact Amber to obtain a Quest Quanum login if you do not already have one to
verify if patients are new or existing. Otherwise, a quick way to check this is to access a
patient’s vitals to see if they have had vitals from past years.
4. Primary assessment - If a patient is getting a physical AND has other complaints
separate from the physical, make sure to mark the physical as the PRIMARY issue under
Assessment. This can be done by clicking the checkbox to the very left of the ICD
code/Diagnosis. If the patient has 2+ complains w/o a physical, then either of them can
be the primary issue.
5. Complaints separate from physical - Do NOT remove the phrase “Pt would also like to
address the following c/o separate from the physical:” in the HPI if you do discuss other
complaints during a physical. Otherwise, the separate complaints will be considered a
part of the physical as opposed to a separate component that needs to be billed
separately. You are free to remove it if the patient does not any other complaints.
6. Exam contradictions - Make sure the Exam matches with the HPI. For instance, if a
patient has a rash, modify the exam from the default “SKIN – no rashes, no lesions” to a
description of said rash. Some providers will choose to document this themselves, but
other times they will prompt you to write it instead. Either way, ensure the information
in the Exam does not contradict the patient’s complaints and be sure to ask the provider
if there is a specific part of the Exam they would like you to document!
7. Drug doses - Be specific when documenting the doses of medications to avoid
confusion. Specifically, state the total dose and frequency the patient is taking a drug
OR state the dosage of a single tablet/capsule/etc., followed by the amount of pills
taken by the patient, followed by the frequency
a. Correct examples:
i. Metformin HCl 1000 mg PO QD
ii. Metformin HCl 500 mg tablet, 2 tablets PO QD
b. Incorrect example:
i. Metformin HCl 500 mg tablet PO QD (How many tablets is the patient
taking? Do we know if they are taking two daily or just one?)
8. Hospital discharge CPT - The CPT code for a hospital F/U (that is, the patient was
ADMITTED to the hospital, NOT just seen at an ER and discharged shortly after) is 99495
9. Medicare Physical
a. There are Medicare Physical HPI TextExpanders that should be used (they can be
found upon just searching “medicare”), but otherwise, the Plan remains the
same as a regular Annual Physical.
b. CPT Codes
i. G0402 – age 65, Welcome to Medicare Annual Physical
ii. G0438 – age 66-67, Initial Medicare Physical, used >1 year after Welcome
to Medicare physical
iii. G0439 – age 67+, Subsequent Medicare Physical, always used after the
Initial Medicare Physical