Thursday, February 14, 2013

Coding and Documentation

In need of coding help?

AAPC's Coding Edge Magazine published an article on  documentation and offered the following tips:
  • Reports Don't Need to Be Lengthy to Be Complete
    • Minimum requirements that need to be in the medical record are the following:
      • 1. History of present illness (HPI)
      • 2. Examination
      • 3. Medical Decision Making (MDM) components
    • If you are documenting radiology, you must document the technique as well as the findings of the study
  • Documentation Must Be Relevant
    • Extraneous documentation can do more harm than good
    • Stick to what's relevant and be thorough
  • Documentation Must Support Specific Coding
    • Select the code that accurately identifies the service or procedure performed
    • Documentation my support the code you select
  • Document Same-Day Procedure, E/M with Special Care
    • Procedures provided on the same day as an E/M service may cause red flags
    • When you report an additional study your documentation must pass the "highlighter test" - supports the initial service
  • * Important to remember the "golden rule" - "If it isn't documented, it wasn't done"*
To download the full article, please click here: Let Documentation Drive Your Coding

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

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