Thursday, March 20, 2014

Medical Documentation




ACK Coding Tips


 DOCUMENTATION

 
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”

  Beware of the EMR

·         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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