ACK Coding Tips
Medical
Necessity is the overarching criterion
·
Regardless of the volume of documentation
·
How is medical necessity documented ?
To accurately reflect the service provided, the documentation
should occur during, or
as soon as practicable after it is provided.
·
Recommend a policy to address “timely documentation”
·
Cloned notes
·
Notes that make no sense
·
Conflicting information
·
Did you really do everything as reflected on the template?
TEMPLATES
AND OTHER TOOLS
·
History forms
with past history, family history, social history, and system review
o This information
needs to be incorporated by reference appropriately
·
Progress notes
that prompt the provider of documentation Requirements
·
Charge document
o E/M codes don’t
crosswalk
o Include all
levels of E/M services
o Include full
descriptions of E/M services
o Common
procedures
o The electronic
medical record
o Medical
Necessity, above all else !!!
AccuChecker is your COMPLETE tool for
Medical Billing
Ø Medical Coding
Ø CPT
Ø ICD-10
Ø HEDIS
Ø PQRS
Ø Claims Scrubber
For more details or information on
Consulting Services and Seminars, please call 305-227-2383 or 1-877-938-9311
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