Coding, Chart Documentation and Reimbursement - Thurston ...

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Coding, Chart Documentation and Reimbursement Documentation Best Practices • Clearly document complete Treatment plans to include targeted issues of treatment, specific goals and objectives, and interventions you will employ • Complete operative reports immediately after an operation and/or maintain an operative progress note in the chart until completed report is available • Create and maintain a policy for standardizing abbreviations, acronyms, and symbols 10
Agenda Coding, Chart Documentation and Reimbursement • Principles of Medical Documentation • Common E/M Service Documentation Errors 11
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