Procedure guides

Documentation that holds up

Category-specific guidance with interactive checklists and modifier risk assessment.

E/M coding: documentation that holds up

Evaluation and management codes represent the highest volume of claims in most practices. 99214 alone accounts for more billed services than any other CPT code — and faces the highest audit rates.

Documentation checklist

Document presenting problem with specificity

Note number and complexity of conditions addressed

Detail data reviewed (labs, imaging, outside records)

Explicitly state risk level of management options

If time-based: document total time including non-face-to-face

Avoid templated language that doesn't differentiate complexity

Link assessment directly to plan for each problem

0 / 7 complete

Modifier risk assessment

Mod 25 Moderate

Separately identifiable E/M on same day as procedure.

UHC and BCBS audit most aggressively

Mod 95 Low

Synchronous telemedicine visit. Same documentation as in-person.

Verify payer-specific telehealth policies