AMA CPT® Assistant - 1995 Issue 1 (January)

Medical Records Check-up (Spring 1995)

Spring 1995 pages 9-11 Medical Records Check-up Do you ....     Write legibly or use transcription?     Use clear, concise language?     Date and sign entries? (Particularly if in a group practice?)     Avoid improper alteration of the medical record?     Avoid using non-standard abbreviations?     Document what a patient tells you and what you tell a patient?     Obtain and file patient authorization for record release? (Review applicable state laws on release of medical records)     Include consulting physicians reports/notes?     Include disability reports and other information from others participating in patient's care?     Sign reports and dictation only after review? Medical Records Check-up. CPT® Assistant. 1995; Spring...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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