Basics Of Coding And Medical Record Documentation
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The document discusses the basics of medical coding and record documentation. It covers the key components of a medical record including that it serves as a medical, legal, and compliance document. It outlines the patient's care and treatment. The document also discusses the key components of evaluation and management (E&M) codes including history, examination and medical decision making. It notes the requirements for documenting new versus established patient visits. The presentation emphasizes that documentation is critical for appropriate coding, reimbursement and defending medical necessity.
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This document summarizes key points from a presentation on the importance of thorough and accurate nursing documentation. It discusses how poor documentation can lead to legal issues like malpractice lawsuits and loss of a nursing license. Specific documentation best practices are covered, like using objective language, signing entries, and avoiding unapproved abbreviations. Common charting mistakes are outlined, such as failing to record pertinent health information or nursing interventions. The presentation emphasizes that documentation is essential to provide a clear record of a patient's care and can be critical in legal cases.
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Sarah Leydon has over 15 years of experience in revenue cycle management and practice management for medical practices. She founded AAAMB, Inc in 2008 which manages the revenue cycle for over 250 practices nationwide with over $40 million in annual revenue. Her experience includes contract negotiations, practice analysis, electronic medical records implementation, accounts receivable and payable management, insurance billing and collections, and serving as an instructor for medical billing and coding.
Documentation
The document discusses documentation in healthcare, including its definition, purposes, principles, types of records, and methods of communication and documentation systems. Documentation involves recording all interactions with clients and is used for communication, quality assurance, reimbursement, legal accountability, research, and other purposes. Common types of records include outpatient/inpatient records, nurses' notes, doctors' orders, lab reports, and intake/output charts. Methods of communication include shift reports, telephone reports, and evaluation reports. Documentation systems include source-oriented records, problem-oriented records, and computerized documentation.
Lab-Fin_EHR.docx
Effective health care documentation for electronic health records should provide clear, legible, and efficient information for clinical management and reimbursement. Accurate documentation of all patient monitoring, treatment, and updates is critical for optimal patient care and protects providers from legal issues. Key factors include providing factual, consistent, accurate, current, legible, and signed information without unnecessary jargon or abbreviations.
Lab-Fin_EHR.docx
Effective health care documentation for electronic health records should provide clear, legible, and efficient information for clinical management and reimbursement. Accurate documentation of all patient monitoring, treatment, and updates is critical for optimal patient care and protects providers from legal issues. Key factors include providing factual, consistent, accurate, current, legible, and signed information without unnecessary jargon or abbreviations.
Coding Guidelines For Evaluation And Management Services In Internal Medicine...
Evaluation and management (E/M) services play a crucial role in the practice of internists, and accurate coding for these visits is essential for the financial well-being of medical practice. However, determining the appropriate level of billing for an E/M code can be challenging for many physicians.
Coding Guidelines For Evaluation And Management Services In Internal Medicine...
Evaluation and management (E/M) services play a crucial role in the practice of internists, and accurate coding for these visits is essential for the financial well-being of medical practice. However, determining the appropriate level of billing for an E/M code can be challenging for many physicians.
Medical coding best-practices_for_emergency_departments (1)
In this paper, you will learn about the unique medical coding and billing challenges posed by emergency departments and the coding best practices to ensure optimal reimbursements.
Maintenance of records and reports copy
This document discusses the importance of maintaining accurate and complete records in community health nursing. It outlines the purposes of records such as communication between healthcare providers, planning care, auditing health agencies, research, and education. The document describes different types of records including family records, anecdotal records, clinical records, doctors' order sheets, nurses' sheets, and registers. It provides guidelines for proper recording, including documenting date, time, legibility, permanence, accuracy, and use of accepted terminology. The value of records for nurses, families, doctors, and organizations is explained. Different reports used in community health settings are also outlined.
Documentation.pptx
1) Nursing documentation is important for communication, accountability, and providing quality patient care. It involves recording all relevant information about a patient's condition, treatment, and the nursing care provided.
2) There are various methods of documentation, including traditional source-oriented records, problem-oriented records, and nursing process frameworks like PIE (Problem, Intervention, Evaluation) charting. Electronic health records are also increasingly common.
3) Proper documentation principles include recording objective factual information, using accepted terminology, keeping accurate and organized records, maintaining client confidentiality, and signing and dating all entries. Thorough documentation is essential for ensuring safe and coordinated care.
Creating a Compliance Culture
The document discusses creating a compliance culture in healthcare organizations by focusing on clinical documentation and medical coding. It emphasizes establishing a culture where stakeholders view compliance as an opportunity rather than a threat. This involves using HIPAA, CMS, and AHIMA standards to drive improved patient outcomes, team effectiveness, and reimbursements. Key areas of focus are medical necessity of care, risks of electronic health record documentation, and need for complete clinical documentation to justify codes and payments. The first steps outlined are aligning goals, identifying opportunities, and securing executive support for a multidisciplinary team to implement changes.
Nursing Foundation Documentation Nursing Ist Sem Students
The document discusses documentation, recording, and reporting in healthcare. It defines documentation as written records used as proof of patient care. Records provide permanent documentation of patient information and care. Recording involves making entries in a patient's chart or record. Reporting refers to sharing information about patient care orally, in writing, or electronically. Accurate documentation, recording, and reporting are important for communication between providers, planning care, reimbursement, legal purposes, and more. Guidelines for documentation include being factual, timely, legible, using accepted terminology and correct spelling.
Documentation in nursing
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
Clinical Documentation Improvement for Physician E/M Coding
This document outlines a presentation on clinical documentation improvement for physician E/M coding. The presentation will cover understanding the range of E/M codes with an emphasis on code sequences, E/M coding requirements from CPT, typical encounters for different code levels, issues like new vs. established patients, coding by time requirements, the importance of the chief complaint, undercoding and overcoding risks, CMS documentation guidelines, the role of medical decision making, examination templates, overall templates for E/M services, and who can perform different parts of the E/M service. The presenter, Duane C. Abbey, is an experienced healthcare consultant and educator who will review these topics to help optimize reimbursement under prospective payment systems.
Patient often has at least some anxietyFear of dia.docx
Patient often has at least some anxiety
Fear of diagnosis
Discomfort with lack of privacy
Fear of high costs/ time off work
Fear of pain or discomfortDifficult for MD’s and nurses
Administrative role to provide a supportive environment
Patient judge medical care based upon their entire experience, not just physician quality
Parking
Registration
BillingDemeanor of manager may dispel complaints
Listen, empathize, change what you can, however….
Medical decisions are still the MD’s responsibility
Timeliness
Respect that their time is as important as yoursProvider attitude
Happy doctors and nurses, good “bedside manner”Complaints may be a symptom of a larger problem
Patient anxiety
Financial concerns
Too little time with MDMD didn’t listenStaff was rude, uncaringWait too longMD took calls during examPoor teaching, no explanation for testsPoor explanation of billing, insurancePoor communication between specialist and primary care
Top complaints revolve around time, respect, and patient instructionGather facts, information
Remember subjective patient information is only one side of the story
Patients may be misunderstanding the purpose for tests or MD decisionsEasier to resolve when organizational systems are in place
Identification of the problem
Reactive: Complaints
Proactive: Data collection such as surveysAnalyze data to identify trendsCommunicate information in an impartial way to staff, leadersImplement actions to reverse trendsContinuous evaluation to assure effectiveness
Inform patients of why the survey is being done
What the data will be used for
Confidentiality; that answers won’t affect future medical careProvide a stamped envelope
Put no burden on the patient
If a patient puts their name and a personal note provide a personal responseCommunicate results to staff
Complaint resolution/ patient relations is an area where an administrator can make a tremendous impact
May reduce malpractice claimsNeed MD support
Establish peer review processes for MD’s
MD’s should be evaluated by other MD’s
Put in place a formal , objective complaint resolution systemCommunicate continuously with staff
Hca 346 ambulatory care administration
Professor Haislip
Chapters 3 & 5
Basis of any quality program is to figure out what the customer wants and needs while meeting or exceeding their expectations.
Driven from theme of customer-driven market
Customer service principles (ex: Six Sigma) and the common methodologies, combined with the ten commonsense principles (CSPs) and personal experiences, will deliver a customer-focused culture.
Figure 3.1
Chapter 3: Engineering the customer connection
Quality Function Development (QFD)- an effective team approach to designing products and services that involves key stakeholders from the organizations that are responsible for what the customer uses or purchases
notably called the voice of the customer
QFD and voice of the consumer refers to development of prioritized set of customers wants and nee.
Unit-IV EMR b.sc II sem 2022.pptx
The document discusses electronic health records (EHRs), including their purpose, components, and functions. It provides definitions of key terms like EHR, EMR, and PHR. It also lists teaching methods used like lectures, discussions, and practical sessions on simulated EHR systems. The goals are to explain the use of EHRs in nursing practice and describe latest standards and interoperability trends.
Documenting and reporting
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
Similar to Basics Of Coding And Medical Record Documentation (20)
Improving ICD-10 Documentation by Querying Providers
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Coding Guidelines For Evaluation And Management Services In Internal Medicine...
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Nursing Foundation Documentation Nursing Ist Sem Students
Nursing Foundation Documentation Nursing Ist Sem Students
Clinical Documentation Improvement for Physician E/M Coding
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Patient often has at least some anxietyFear of dia.docx
Basics Of Coding And Medical Record Documentation
- 1. Basics of Coding and Medical Record Documentation Presented by Angie Nolan, CHA, CPC, CPC-I, PCS, RMA HIMS Educator Banner Medical Group
- 4. Functions of the medical record
- 5. Key components of E&M codes
- 6. Basic E&M coding-new patient services
- 7. Basic E&M coding-established patient services
- 9. Serves as a legal document
- 10. Serves as a compliance document
- 11. Outlines the patient’s care and treatment rendered
- 13. Dictation for documentation should be efficient and thorough
- 14. Date and time should accompany all entries
- 17. Reduces medical errors and professional liability exposure
- 21. Provides clinical data for education
- 22. Provides clinical data for research
- 23. Promotes continuity of care among physicians
- 25. History of present illness-4 of 8 elements
- 26. Review of systems-up to 10 or more organ systems (or a few systems and statement “all other systems have been reviewed and are negative”)
- 27. Past, family, and social history-all 3 elements (non-contributory is not acceptable documentation)
- 28. Examination
- 29. For a general Multi-System Exam - At least 2 bullets from each of 9 body systems or areas
- 30. Or for a single organ system exam please see the 1997 documentation guidelines for requirements for that organ system
- 32. Straightforward
- 33. Low
- 34. Moderate
- 36. A best defense is always a good defense
- 37. Document what you do and do what you document
- 39. CMS Evaluation and Management Services Guide-2008
- 40. CMS 1995 Documentation Guidelines