Chapter 4 - Medical Documentation - Lesson 2

Lesson 2 - General Principles Of Medical Record Documentation

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Side ASide B
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:
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...
- Ensure that services billed were actually provided - Ensure that the services are consistent with insurance contract benefits - Ensure medical necessity and appropriateness of...
Medicare will always pay for a service that is reasonable and necessary.a. Trueb. 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. Trueb. 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...
Failure to document medical necessity and failure to document services furnished and billed are often the focus of fraud initiatives.a. Trueb. False
a. True
American Medical Association
Evaluation and Management
Current Procedural Terminology
Centers for Medicare and Medicaid Services
3 Terms for Medicare Administrative Contractors
1.  Fiscal Intermediaries2.  Fiscal Agents3.  Fiscal Carriers
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...
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 Physician2.  Consultant must RENDER an opinion and send a REPORT3,  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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