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Demystifying Medical Documentation

Demystifying Medical Documentation

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This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.
This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.

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Published by: adultmedicalconsultants on Oct 27, 2008
Copyright:Traditional Copyright: All rights reserved

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01/14/2013

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Created byThe Lung Doctor for e-Medtools
MedicalMedicalTemplatesTemplates
Demystifying Medical Documentation
 
Created byThe Lung Doctor for e-Medtools
A Quick Review of A Quick Review of Medical DocumentationMedical DocumentationRequirementsRequirements
 
Created byThe Lung Doctor for e-Medtools
Patient EncountersPatient Encounters
The Centers for Medicare and MedicaidServices (CMS) has published definitions anddocumentation guidelines for the keycomponents of a medical encounter note,using CPT codes.

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