Coding, Chart Documentation and Reimbursement - Thurston ...
Coding, Chart Documentation and Reimbursement - Thurston ...
Coding, Chart Documentation and Reimbursement - Thurston ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Coding</strong>, <strong>Chart</strong> <strong>Documentation</strong> <strong>and</strong><br />
<strong>Reimbursement</strong><br />
Tips for documenting medical records<br />
• The medical record should be complete <strong>and</strong><br />
legible with a logical flow. It should also be<br />
dated <strong>and</strong> authenticated by the physician.<br />
• <strong>Documentation</strong> should support the intensity<br />
of the evaluation <strong>and</strong>/or treatment, including<br />
thought processes <strong>and</strong> the complexity of<br />
medical decision-making.<br />
• The patient’s progress including response to<br />
treatment, change in diagnosis <strong>and</strong> patient<br />
non-compliance should be documented.<br />
6
Change language