Health Information Technologies and Processes

Progress Note Requirements

  • 1.  Progress Note Requirements

    Posted 28 days ago
    Hi,  This feels like a very basic question however I am being challenged.  It has always been belief that physician progress notes should not only be dated but timed, time of visit.  Their outpatient notes are not reimbursed by time spent but time spent can be considered in selection of an E&M code.
    It has also always been my belief that from a medico legal standpoint it is important to document the time the patient was seen.
    Can anyone steer me a CMS standard or other recognizable best practice.  Thank you.

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    Kathryn Boyes
    Director, HIM
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  • 2.  RE: Progress Note Requirements

    Posted 27 days ago
    Refer to:

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

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    Mary Meysenburg, MPA, RHIA, CCS

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