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Chronological order for writing a neuropsychological report.

Luz Posted Tue 12th of November, 2019 15:25:44 PM
Are there any CMS guidelines regarding the chronological order for writing a neuropsychological report? One of our neuropsychologists write the impressions and recommendations before the history of present illness. Your response is appreciated. If there is a guideline available regarding this request please let me know. Thank You.
SuperCoder Answered Wed 13th of November, 2019 06:21:59 AM

Hi Luz,


Thanks for your question.


CMS guidelines indicate the following order for 3 key components of the E/M services:


  1. History
  2. Examination
  3. Medical Decision Making


This chronological order should be followed to make your documentation understandable. Doctor should know history of the present illness first, then he will examine the patient, and then he will decide the treatment plan. Treatment plan includes impressions, recommendations, medical decision making etc.


Please feel free to write if you have any question.



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