We have been having a hard time definitively telling our providers whether an Exam and RoS need to be documented, and how extensive they need to be, in order to bill for Transitional Care Management. Is there anyone who could help shed some light on this subject? I have been looking through the guidelines, on CMS, MLN, AAPC and I cant find anything that touches on the subject of exams and RoS, it all goes over MDM.

Thank you,

Jessica Wegner, CPC-A