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Chapter 4 - Medical Documentation - Lesson 2


Lesson 2 - General Principles Of Medical Record Documentation
  
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State how Medicare Defines "Medically Necessary"
 
Services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Identify the broadly accepted maximum for documentation.
 
If it isn't documented, it didn't happen.
List the three most important requirements for medical records:
 
Correct
Complete
Legible
What should medical record documentation always support on the health CMS-1500 claim form (select all that apply):
- Written Procedures
- CPT Codes
- ICD-9-CM Codes
- Dollar Amounts
 
- CPT Codes
- ICD-9-CM Codes
What are reasons for accurate documentation from the PAYER'S point of view (Select all that apply):
- Ensure that services billed were actually provided
- Ensure that services billed were performed by a licensed physician
- Ensure that the services are consistent with insurance contract benefits
- Ensure medical necessity and appropriateness of the services provided
 
- Ensure that services billed were actually provided
- Ensure that the services are consistent with insurance contract benefits
- Ensure medical necessity and appropriateness of the services provided
Medicare will always pay for a service that is reasonable and necessary.
a. True
b. False
 
b. False - Coverage can be limited if the service is provided more frequently than allowed.
Mistakes, errors, misunderstanding of the rules or negligence are not necessarily considered fraud.
a. True
b. False
 
a. True - Mistakes, error, misunderstanding of the rules or negligence are not necessarily considered fraud. Suspicions arise, however, if errs are consistently in favor of the provider. Mistakes can result from a difffering but reasonable interpretation of the rules.
Failure to document medical necessity and failure to document services furnished and billed are often the focus of fraud initiatives.
a. True
b. False
 
a. True
AMA
 
American Medical Association
E/M
 
Evaluation and Management
CPT
 
Current Procedural Terminology
CMS
 
Centers for Medicare and Medicaid Services
3 Terms for Medicare Administrative Contractors
 
1. Fiscal Intermediaries
2. Fiscal Agents
3. Fiscal Carriers
ABM
 
Advanced Beneficiary Notice
What is an Advanced Beneficiary Notice?
 
An agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. The patient agrees to pay for the services; also known as : Waiver of liability agreement or responsibility statement
What is a Signature Log?
 
A list of all staff members, names, titles, signatures and initials.
What are the 4 R's of Documentation Guidelines?
 
1. REQUESTING Physician
2. Consultant must RENDER an opinion and send a REPORT
3, Requesting Physician must document the REASON for the consult.
What could be the 5th R of Documentation Guidelines?
 
Consultation RETURNS - Consulting Physician must RETURN the patient to the requesting Physician.

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