Documenting Clinical Findings and Diagnosis

3 CE Credits

Hour 1: Utilizing the history in the evaluation and management process to determine triage based upon complaints coupled with system review, past medical history, family and social history, and surgical history.

Hour 2: Correlating vitals, orthopedic testing, neuromuscular examination, and test results inclusive of basic and advanced imaging and electrodiagnostic testing as clinically indicated to determine an accurate diagnosis, prognosis, and treatment plan.

Hour 3: How to create accurate ICD-10 codes inclusive of causality and sequella codes. Ensuring that all pathologies uncovered in the evaluation and management process are included in the diagnosis and that every area treated in the body has a corresponding diagnosis. Understanding the role of re-evaluations when updating diagnosis.

Course Objective: To have documentation that meets the coding requirements and elements in an Evaluation and Management encounter (99202-99203-99204-99205).