Chapter 4 - Medical Documentation - Lesson 2

Lesson 2 - General Principles Of Medical Record Documentation
Created Apr 14, 2010
by jerzegirl
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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...
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...
- CPT Codes - ICD-9-CM Codes
What are reasons for accurate documentation from the PAYER'S point of view (Select all that...
- Ensure that services billed were actually provided - Ensure that the services are consistent...
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...
a. True - Mistakes, error, misunderstanding of the rules or negligence are not necessarily...
Failure to document medical necessity and failure to document services furnished and billed...
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...
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, ...
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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