Medical Record Chart Analyzer : Documentation Rules and Rationales with Exercise

by Grider, Deborah J.

• ISBN13: 9781579472696
• ISBN10: 1579472699
• Format: Paperback
• Copyright: 2002-08-01
• Publisher: AMERICAN MEDICAL ASSOCIATION

Summary

The quality of coding is an important factor in determining the financial health of a practice. When problems occur they must be solved quickly. But before they can be solved, they must be found. Medical Record Chart Analyzer includes medical record documentation with a systematic guide to the medical record review process for the physician's or outpatient office. Learning objectives are included at the beginning of most chapters to overview chapter content and help measure progress. Medical chart review and coding tips are located throughout the book. The application exercises allow the reader to master each topic one chapter at a time. Also included is a final examination to test documentation and auditing skills. By the end of the book, the reader will be able to conduct reviews independently. This book will prepare the reader to accomplish the following objectives: Understand the specifics about medical record chart requirements and the review process Review

Table of Contents

The Medical Record	1	(30)
Defining the Medical Record and the Role of the Medical Record Administrator	1	(1)
Medical Record Accountability and Privacy and Release of Medical Record Information	2	(1)
Components of the Medical Record	3	(1)
Medical Record Entries	4	(1)
The Patient Registration Form	4	(2)
Financial Responsibility and Assignment of Benefits	6	(1)
Consent for Treatment	7	(1)
Medicare Lifetime Beneficiary Claim Authorization	8	(1)
Patient Medical and Interval History	8	(3)
Problem List and Medication Sheet	11	(1)
Factors That Affect Learning (Learning Needs)	11	(3)
Preventive Screenings	14	(1)
Advance Beneficiary Notice (Medicare Waiver of Liability)	14	(3)
Consent Form for Invasive Procedure	17	(1)
Patient Encounters	17	(1)
Laboratory Reports	18	(1)
Report of Procedures	19	(1)
Termination or Withdrawal of Treatment	19	(2)
Immunization Records	21	(1)
Record Retention	21	(10)
Documentation Basics	31	(14)
A Brief History of Medical Record Documentation	31	(2)
Coding and Reimbursement	33	(1)
The Purpose of Documentation	33	(1)
The Medical Record as a Legal Document	33	(1)
Progress and SOAP Notes	34	(4)
Checkpoint Exercises	38	(1)
The Operative Report	38	(1)
Documentation Guidelines	39	(2)
How Documentation Affects the Coding Process	41	(1)
Coding and Compliance Tips	41	(4)
Understanding the Evaluation and Management Codes and the Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines	45	(38)
Evaluation and Management Documentation Guidelines from CMS	45	(1)
Medical Record Documentation and Its Importance	46	(1)
Medical Necessity and Diagnosis Coding (ICD-9-CM) for Physician Services	47	(1)
Evaluation and Management Services	48	(1)
Key Components and Contributory Factors	49	(2)
Instructions for Selecting a Level of E/M Service	51	(1)
Definitions of Key Components	52	(22)
The Future of the CMS E/M Documentation Guidelines	74	(1)
Visits Dominated by Counseling and/or Coordination of Care	75	(8)
Other Evaluation and Management Services	83	(12)
Consultation Guidelines	83	(3)
Preventive Medicine Services	86	(1)
Components Used to Distinguish Between Preventive and Problem-Related Services	87	(2)
Prolonged Physician Service without Direct (Face-to-Face) Patient Contact	89	(6)
Compliance in the Medical Practice	95	(22)
Compliance	95	(1)
Fraud and Abuse	96	(1)
Civil Monetary Penalties Law	97	(1)
Federal False Claims Act	98	(1)
Carrier Audits	98	(3)
Benefits of a Compliance Program	101	(1)
Compliance Plan Elements	102	(5)
Designation of a Compliance Officer	107	(1)
Education and Training	107	(1)
Communication	108	(1)
Auditing and Monitoring	109	(1)
Disciplinary Action	110	(1)
Corrective Action	110	(1)
Nonemployment or Nonretention of Sanctioned Individuals	111	(1)
A Successful Compliance Program	111	(6)
Chart Audit Process-The Medical Record Review	117	(24)
The Audit Process	117	(1)
Top Coding and Documentation Errors	117	(1)
Auditing and Analyzing Your Medical Records	118	(3)
Determining the Type of Audit	121	(3)
Preparing for the Audit	124	(4)
Performing the Chart Audit	128	(6)
After the Audit	134	(7)
Analyzing the Office Medical Record	141	(34)
Chart Auditing Step by Step	141	(1)
Beginning the Audit Process	142	(33)
Audit Reporting Mechanisms	175	(14)
Analysis and Reporting	175	(8)
Ongoing Monitoring	183	(1)
Education and Training	183	(1)
Corrective Action Plan	184	(1)
What Triggers a Third-Party Payer Audit	184	(5)
The Surgical Medical Record	189	(28)
Coding Based on Standard of Surgical Practices	189	(1)
The Surgical Package	189	(1)
Surgery Coding Rules	190	(2)
Correct Coding Initiative (CCI)	192	(1)
Unbundling	193	(2)
Separate Procedures	195	(1)
Scope Procedures vs Open Procedures	196	(1)
Diagnostic Services vs Therapeutic Services	196	(1)
Add-on Codes	197	(1)
Stand-Alone Codes and Indented Codes	198	(1)
Beginning the Surgical Audit Process	198	(19)
Take the Auditing Challenge	217	(24)
Take the Auditing Challenge-Surgical Records	241	(26)
Appendix A CMS Exam Tables for 1997 Guidelines	267	(22)
Appendix B CMS Documentation Guidelines for 1995 and 1997	289	(22)
Appendix C Audit Forms	311	(18)
Appendix D Valuable Web Sites	329	(4)
Appendix E Terminology	333	(8)
Appendix F Answer Key	341	(24)
Index	365