9781603592949

Table of Contents


	List of Figures	viii
	List of Tables	x
	About the Author	xiii
	Preface	xv
	Acknowledgments	xix
1	The Medical Record	1
	Defining the Medical Record and the Role of the Medical Record Administrator	1
	Medical Record Accountability and Privacy and Release of Medical Record Information	2
	Components of the Medical Record	3
	Medical Record Entries	4
	The Patient Registration Form	4
	Financial Responsibility and Assignment of Benefits	6
	Consent for Treatment	7
	Medicare Lifetime Beneficiary Claim Authorization	8
	Patient Medical and Interval History	8
	Problem List and Medication Sheet	11
	Factors that Affect Learning (Learning Needs)	11
	Preventive Screening	14
	Advance Beneficiary Notice (Medicare Waiver of Liability)	14
	Consent Form for Invasive Procedure	21
	Patient Encounters	22
	Laboratory Reports	22
	Report of Procedures	23
	Termination or Withdrawal of Treatment	23
	Immunization Records	26
	Record Retention	26
	HIPAA Privacy Regulations	29
	Key Terms	40
	Test Your Knowledge	41
2	Documentation Basics	43
	A Brief History of Medical Record Documentation	43
	Coding and Reimbursement	45
	The Purpose of Documentation	45
	The Medical Record as a Legal Document	45
	Progress and SOAP Notes	46
	Dictation vs Templates	50
	Checkpoint Exercise	54
	The Operative Report	54
	Documentation Guidelines	62
	How Documentation Affects the Coding Process	63
	Coding and Compliance Tips	63
	Key Terms	64
	Test Your Knowledge	65
3	Understanding the Evaluation and Management Codes	67
	Evaluation and Management Services Defines by the CPT Codebook	67
	Key Components and Contributory Factors	69
	Instructions for Selecting a Level of E/M Service	75
	Definitions of Key Components	77
	Evaluation and Management Documentation Guidelines from CMS	78
	Medical Record Documentation and its Importance	79
	Medical Necessity and Diagnosis Coding (ICD-9-CM) for Physician Services	81
	Documentation Guidelines for Evaluation and Management Services, 1995 vs 1997	83
	Checkpoint Exercise 1	91
	Checkpoint Exercise 2	101
	Visits Dominated by Counseling and/or Coordination of Care	115
	Key Terms	116
	Test Your Knowledge	118
	Sources	122
4	Other Evaluation and Management Services	123
	CPT Consultation Guidelines	123
	Reporting Consultant for CMS	128
	Reporting the Nursing Visit Code 99211	134
	Preventive Medicine Services	136
	Observation Care Discharge	139
	Prolonged Physician Service with Direct (Face-To-Face) Patient Contact	140
	Discharge Services	141
	Nursing Facility Discharge Services	142
	Case Management Services	143
	Physician Standby Services	144
	Care Plan Oversight	144
	Critical Care Services	145
	Neonatal and Pediatric Critical Care Services	151
	Key Terms	155
	Test Your Knowledge	156
	Endnotes	159
	Sources	160
5	Compliance in the Medical Practice	161
	Coding and Reimbursement	161
	Privacy and Confidentiality	162
	The History of Compliance	163
	Fraud and Abuse	165
	Civil Monetary Penalties Law	166
	Federal False Claims Act	167
	Carrier Audits	167
	Benefits of a Compliance Program	170
	Compliance Plan Elements	171
	Designation of a Compliance Officer	176
	Education and Training	177
	Communication	178
	Auditing and Monitoring	178
	Disciplinary Action	179
	Corrective Action	179
	Nonemployment or Nonretention of Sanctioned Individuals	180
	A Successful Compliance Program	181
	The National Correct Coding Initiative	181
	Key Terms	199
	Test Your Knowledge	201
	Sources	204
6	Chart Audit Process�The Medical Record Review	205
	The Audit Process	205
	Top Coding and Documentation Errors	205
	Auditing and Analyzing Your Medical Records	206
	Steps in the Audit Process	211
	Performing the Chart Audit	214
	The Chart Audit Process	220
	After the Audit	220
	Audit Tool	220
	Key Terms	227
	Test Your Knowledge	231
7	Auditing the Office Medical Record	233
	Chart Auditing: Step by Step	233
	Beginning the Audit Process	235
	Test Your Knowledge	261
8	Audit Reporting Mechanisms	273
	Analysis and Reporting	273
	Ongoing Monitoring	283
	Education and Training	283
	Corrective Action Plan	284
	What Triggers a Third-Party Payer Audit?	284
	Key Terms	285
	Test Your Knowledge	286
9	The Surgical Medical Record	289
	Coding Based on Standard of Surgical Practice	289
	Surgery Coding Rules	289
	CPT Global Surgery Package	290
	CMS Surgical Package	291
	National Correct Coding Initiative (NCCI)	299
	Unbundling	300
	Separate Procedures	313
	Scope Procedures vs Open Procedures	314
	Diagnostic Services vs Therapeutic Services	315
	Add-On Codes	315
	Stand-Alone Codes and Indented Codes	316
	Beginning the Surgical Audit Process	316
	Checkpoint Exercise	321
	Key Terms	326
	Test Your Knowledge	328
	Endnotes	329
	Sources	329
10	Auditing Diagnostic Radiology Services for Physician Services	331
	Introduction	331
	The Anatomy of a Radiology Report	334
	ICD-9-CM Guidelines for Diagnostic Radiology Services	336
	Beginning the Radiology Audit	338
	Insurance Carrier Policies with Regard to Radiology Services	339
	The Radiology Audit Tool	339
	Test Your Knowledge	343
11	Regulatory Guidance	351
	Why Auditing is Vital to the Health of the Medical Practice	351
	What Triggers an External Audit?	353
	Comprehensive Error Rate Testing Program (CERT)	361
	Recovery Audit Contractors (RAC)	367
	The Corporate Integrity Agreement (CIA)	388
	Conclusion	402
	Key Terms	402
	Test Your Knowledge	404
	Endnotes	408
	Sources	409
Appendix A	CMS Exam Tables for 1997 Guidelines	411
Appendix B	Audit Forms	433
Appendix C	Valuable Web Sites	471
	Glossary	473
	Index	481