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  • Ask the Expert E/M Exams

    Documenting a Plan of Care


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    We often see lack of documentation for a glaucoma plan of care. Most of our physicians use the abbreviation “CPM” as the plan of care. Is this abbreviation (and only this abbreviation) sufficient for moderate risk of patient management?

    Answer:
    Although reviewers may be familiar with “CPM” to mean “continue present management,” you should include a list of common abbreviations used for any chart review. Best practice is to state what that management is, such as “continue observation” or “continue XXX drop once a day.” Without specific documentation, auditors would need to search for the current management, and that may not occur or be present for their review. 
    Be sure to include when the physician wishes to follow up with the patient. Your plan narrative should cover all aspects of the medical decision-making, the exact care management for each problem addressed during the visit and current assessment (e.g., stable, worsening, etc.).
    Visit aao.org/em for additional evaluation and management (E/M) coding guidance.