Documentation Guides
Complete documentation guides for 35+ medical procedures. Learn requirements, billing tips, and how Scribeable automates compliance.
Office visits, consultations, and hospital services
Established patient office visit with low level of medical decision making.
Established patient office visit with moderate level of medical decision making.
Established patient office visit with high level of medical decision making.
New patient office visit with low level of medical decision making.
New patient office visit with moderate level of medical decision making.
New patient office visit with high level of medical decision making.
Initial hospital admission with comprehensive evaluation.
Daily hospital visit with moderate complexity decision making.
Evaluation and management of critically ill patient, first 30-74 minutes.
Established patient office visit that may not require the presence of a physician or other qualified health care professional. Usually used for nurse visits.
Emergency department visit with low to moderate severity problem requiring expanded problem-focused evaluation.
Emergency department visit with moderate severity problem requiring expanded evaluation and moderate medical decision making.
Emergency department visit requiring detailed evaluation with moderate to high complexity medical decision making.
Emergency department visit for critical or unstable patients requiring high complexity medical decision making and immediate stabilization.
Subsequent hospital care visit with high complexity medical decision making for unstable or significantly deteriorating patients.
Chronic care management services for patients with two or more chronic conditions expected to last at least 12 months, requiring 20 or more minutes of clinical staff time per calendar month.
Remote physiologic monitoring treatment management services requiring 20 or more minutes of interactive communication with the patient per calendar month.
Prolonged evaluation and management service in the outpatient setting, first 30 minutes beyond the typical time for the primary E&M service.
Advance care planning including the explanation and discussion of advance directives by the physician or other qualified health care professional, first 30 minutes face-to-face with the patient, family member(s), and/or surrogate.
Operative and procedural interventions
Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette), single lesion.
Arthroplasty of the knee, condyle and plateau, medial and lateral compartments with or without patella resurfacing (total knee arthroplasty).
Tests and examinations for diagnosis
Diagnostic colonoscopy, flexible, with or without collection of specimen(s) by brushing or washing, through the stoma if applicable.
Colonoscopy, flexible, with biopsy, single or multiple, by forceps technique.
Esophagogastroduodenoscopy (EGD), flexible, transoral, with biopsy, single or multiple.
Electrocardiogram, routine ECG with at least 12 leads, with interpretation and report.
Treatment procedures and injections
Aspiration and/or injection of a major joint (knee, shoulder, hip).
Destruction of premalignant lesion (e.g., actinic keratosis) by any method, first lesion.
Injection of anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance, lumbar or sacral, single level.
Wellness visits and screenings
Comprehensive preventive medicine evaluation for adults 18-39.
Comprehensive preventive medicine evaluation for adults 40-64.
Initial Medicare Annual Wellness Visit with personalized prevention plan.
Subsequent Medicare Annual Wellness Visit including updated health risk assessment and personalized prevention plan.
Mental health evaluations and therapy
Individual psychotherapy session, approximately 45 minutes.
Comprehensive psychiatric diagnostic evaluation.
Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale) with scoring and documentation, per standardized instrument.
Complete documentation guides for medical procedures and CPT codes. Learn billing requirements, documentation tips, and best practices.