Documentation & Coding Archives

Timely Documentation

If it’s Not Documented, It Didn’t Happen Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature authenticating the note. Unless the documentation for a service is completed, including signature, a provider cannot submit the service to Medicare. Medicare states if the service was not documented, then it…

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Best Practices for Timely Documentation

Some providers think of documentation as a drudgery. An endless pile of work with no end in sight. However, there are rules that govern when documentation must be completed. Let’s start this module with an overview to go full circle into the need and definition of contemporaneous documentation of patient health record notes, their completion…

Documentation and Coding Reference Documents

Download Reference Documents The documents found here are references from the profession that outline standards set for documentation and coding. Download, review and save them, as appropriate for your continued reference. AHIMA Standards of Ethical Coding Sample Medical Review Policy

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Coding and Documentation Concerns of the OIG

Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) When it comes to oversight of coding and documentation compliance on the Federal level, the top of the totem pole is the OIG for HHS. The mission of the OIG is to protect the integrity of the Department of Health &…

Locating Medical Review Policies

Tracking Down Your Payer’s MRP When billing any third-party payer, you must be familiar with their Medical Review Policy (MRP). They are usually found within the medical policy section of the carrier’s website but may be made available to clinics through a provider portal. Look for terms such as Clinical Coverage Bulletin, Provider Tools, Reimbursement…

Medical Review Policy – What Does It Mean to Me?

The importance of tracking down the Medical Review Policy (MRP) for each of your contracted carriers is presented in this quick tutorial. The Medical Review Policy is the main source of information that drives successful billing and reimbursement. Avoid time wasted chasing after avoidable denials by learning how to consult the MRP. This quick tutorial…