ED Coding & Reimbursement Alert - 2016 Issue 8
Documentation: 3 Recordkeeping Tips That Will Make Auditors Smile
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Article Overview
This article explains general documentation and recordkeeping practices relevant to medical coding and compliance. It focuses on legibility, appropriate use of abbreviations, and signature expectations when scribes are involved, with references to CMS and Medicare contractor guidance. The piece is aimed at coders, providers, and office staff who want to strengthen documentation quality for review and audit preparedness.
Why This Topic Matters
Clear, consistent medical records help support reported services during review and reduce avoidable documentation problems. The article is useful for practices trying to align everyday note-taking habits with broader compliance expectations.
What You Will Learn
- Why legible clinical documentation matters for review readiness
- How abbreviation practices can affect record clarity
- What to consider when scribes are used in documentation workflows
- Which organizations are referenced in documentation guidance examples
Who Should Read This
- Medical coders
- Physicians and other providers
- Compliance staff
- Billing staff
- Practice managers
- Clinical documentation staff
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