In 2011, Chiropractic Economics magazine published a three-part series by Kathy Mills-Chang, MCS-P, on the evaluation and management (E/M) documentation guidelines. In order to document your history, diagnosis, and treatment of patients in accord with rules set out by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), your patient record should address:

1. Patient history
2. Examination
3. Medical decision-making (MDM)

These three components are addressed in the following three articles, which make reference to the sample worksheet also linked below:

Full story