From the College | Issue: July 2018 |
The adage frequently cited in healthcare settings, “If it isn’t documented, it wasn’t done,” still rings true for the key components required in a patient’s medical record. The note in the medical record must sufficiently describe all of the services furnished to patients on a specific date. The essential requirements to appropriately bill a claim…
The operations management team in healthcare practices is expected to have an effective coding compliance program in place that is continually evaluated and reevaluated. To accurately assess the program’s effectiveness, several outcome indicators must be measured, including error rates in the provider’s documentation and the electronic health record (EHR). Due to increased scrutiny by the…
The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…
Identifying multiple determining factors—including prescription drug management, drug therapy, and chronic illness with severe exacerbation, progression, or side effects to treatment—in determining the level of risk in the medical decision making for a patient with rheumatoid arthritis