tci Medicare Compliance & Reimbursement - 2016 Issue 8

Documentation: Polish Your Recordkeeping Skills to Face Any Kind of Review

Tip: Abbreviations could be your downfall. Unless your medical records are as airtight as your accounts books, you could be in deep trouble at audit time. The following three tips will help you confirm that your documentation is as refined as it needs to be, so you’ll always be able to support the codes that you report. Tip 1: Find A Way to Make Notes Legible. If your physician can’t maintain legible documentation, then your records won’t hold up under audit, and could even be compromising the integrity of your code choices. After all, if your...

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