Codes are determined strictly by the documentation that is held in the medical record. There is an old medical billing adage that states, “If it is not documented, it is not done.” Therefore, when coding, it i
When working with residents, teaching physicians must provide enough documentation to establish their presence and involvement in patient evaluation and treatment. Here are examples of notations that the Centers for Medicare and Medicaid Services will-and will not-accept as sufficient documentation from su...
Nevertheless, I will not back away from the following statement: "We must keep in mind, however, that these tools and notations are not a software design. Eventually, we have to create the real software design, and it will be in some programming language. Therefore, we should not be ...