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