OK, I went to HCFA's web site and dug around for awhile.
Here is the OFFICIAL WORD on documentation. The docs are at:
http://www.hcfa.gov/pubforms/htmltoc.htm
under...
Documentation Guidelines for Evaluation and Management Services:
The medical record documentation guidelines explain appropriate use of the Evaluation
and ManagementCodes
related to Medicare comprehensive multi-system examination and single system
examination.
You specifically want to download either or both of these documents,
which contain in great detail the HCFA documentation requirements
for medicare reimbursement in Uncle Sam's Affluent Land:
http://www.hcfa.gov/medicare/master1.wpd
http://www.hcfa.gov/medicare/master1.pdf
