Congratulations you have completed the entire Documentation & Coding Basics course. Test your knowledge on the basic components of compliant documentation by completing the Documentation & Coding Basics Final Course Assessment

A Signed Note is a Reimbursable Note Medical records chronicle the details and happenings of a Medicare patient’s visits to the office. For services to be eligible for payment, patient records must be properly authenticated and signed according to Medicare’s signature guidelines. Likewise, all third-party payers, not just Medicare, have a signature standard, and for…

Let the Record Reflect… The patient’s health record, whether paper, electronic or a combination of the two, is a legal record. The patient has unprecedented rights as to the use, privacy and protection of this record. Therefore, it must be handled with care and respect. All team members in the practice should hold stewardship over…

Medical Necessity-That Elusive Definition that Frustrates our Profession This module helps to demystify the term Medical Necessity and why it’s important to any provider. In this training module, we explain where the definitions come from, how to find them, what they mean to your billing, and patient explanations. While all the treatment rendered to the…

We Get By With a Little Help from our Scribe There are many strategies for simplifying the sometimes onerous documentation process in a provider’s office. Many busy practices find value in training and using scribe assistants for the doctor to dictate notes to in real time. In turn, they type into the EHR software or…

When is the Deadline? Providers consistently rank documentation as one of their biggest practice headaches. Some avoid it so much that they don’t document at all. Others make temporary marks on travel cards and “will get to it later,” Neither option is compliant. Medical Record Documentation is expected to be completed at the time of…