لایب سان

Ebook details:
عنوان: Medical Record Auditor A Guide to Improving Clinical Documentation in a Changing Health Environment
نویسنده: 9781622021017
ناشر: English
زبان: 9781622021017
شابک: 978-1622021017, 1622021010
حجم: 5 Mb
فرمت: True Pdf

Intro; Title; Copyright; Ancillary Content; Contents; List of Figures; List of Tables; About the Author; Reviewers; Preface; Acknowledgments; Chapter 1 The Role of the Medical Record Auditor; The Purpose of Medical Record Auditing; Role of the Auditor; Qualifications of the Medical Auditor; The Importance of Certification; Test Your Knowledge; Chapter 2 Compliance in the Medical Practice; The Patient Medical Record; Fraud and Abuse Laws; Carrier Audits; Importance of a Compliance Plan; Benefits of a Compliance Plan; OIG Recommended Compliance Plan Elements; A Successful Compliance Program. The National Correct Coding InitiativeCoding Based on Standards of Medical or Surgical Practice; Medically Unlikely Edits; Test Your Knowledge; Resources; Chapter 3 Regulatory Guidance; Coding and Billing Practices are Under a Microscope; External Audit Triggers; The Medical Record Chart Audit; Recovery Audits; Government Audit Programs; The Medicare Appeals Process; Responding to Postpayment Audits and Refund Requests; Audit Prevention; Performing Internal Audits; The Corporate Integrity Agreement (CIA); Test Your Knowledge; Resources; Chapter 4 Documentation Basics. A Brief History of Medical Record DocumentationThe Purpose of Documentation; The Medical Record as a Legal Document; Progress Notes; Soap Notes; Checkpoint Exercise; The Operative Report; Documentation Guidelines; How Documentation Affects the Coding Process; Test Your Knowledge; Chapter 5 The Medical Record; Defining the Medical Record and the Role of the Medical Record Administrator; Medical Record Accountability and Privacy and Release of Medical Record Information; Components of the Medical Record; Advance Beneficiary Notices; Record Retention; Hipaa Privacy Regulations. Test Your KnowledgeResources; Chapter 6 Clinical Documentation Improvement; Documentation Standards; What Is Clinical Documentation Improvement?; Importance of Clinical Documentation Improvement; Establishing a Cdi Program In the Medical Office; The Certified Documentation Improvement Practitioner; Test Your Knowledge; Resources; Chapter 7 Auditing Fundamentals; Top Coding and Documentation Errors; The Importance of Auditing and Analyzing Your Medical Records; Types of Audits; An Overview of the Audit Process; Auditing and Monitoring Guidelines; Audit Analysis and Reporting. Ongoing MonitoringTest Your Knowledge; Resources; Chapter 8 Auditing Evaluation and Management Services; Evaluation and Management Services Defined by the CPT Codebook; Key Components and Contributory Factors; Instructions for Selecting a Level of E/M Service; Evaluation and Management Documentation Guidelines From CMS; The Importance of Medical Record Documentation; Medical Necessity and Diagnosis Coding for Physician Services; Cms Comprehensive Error Rate Testing Program; Documentation Guidelines for Evaluation and Management Services: 1995 vs 1997; Checkpoint Exercise 1.

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