Download Support Tool Far too often, we find a fancy code (maybe a new code) and want to find a way to charge for it. This is completely backward. Documentation must drive coding. This simple visual reminder outlines the process of starting with the documentation and coding from there. Utilize this concept to reinforce the…
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Download Reference Documents Third-party payers provide information on their website to assist providers with meeting the payer’s recordkeeping expectations. It is prudent to know the medical review policy and other administrative policy that relate to the payers with whom the practice does business. Included here are two samples from two different payers that outline guidelines…
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Download Reference Documents Sometimes, when reviewing records to be sent, it’s clear that the note(s) were not properly signed and authenticated. In this instance, all is not lost. Even Medicare provides a way to offer Signature Authentication after the fact. If you have not already reviewed the module in this course regarding signatures, please do…
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Using a Case Summary Template When fulfilling a records request, regardless of the entity requesting the information, we recommend that you always include a Case Summary Letter. The template image shown on the right will help you tell the story of what occurred during treatment and illustrate the case management involved. It should serve as…
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Identify the Source of the Request Prior to responding to a records request, the clinic should identify the requesting party. Is it a payer or third-party? If so, the clinic would refer to contract obligations as well as state and federal rules. If the request is from the patient, the HIPAA Privacy Rule and Right…
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Medical Record Addendums Despite best efforts and good intentions to complete perfect documentation at the time of service, errors and omissions can occur. When that happens, the situation has its own documentation requirements. Failure to properly amend a medical record can make it appear that someone was trying to falsify documentation, and that may be…
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