tci General Surgery Coding Alert - 2022 Issue Q2

Documentation: Get Your Medical Records in Top Shape With These 3 Steps

Establish parameters for timeliness to capture detail. Poor medical record hygiene may lead to poor medical outcomes and poor reimbursement for your surgery practice. That’s why we have this refresher for you, based on our experts’ guidance, plus the words of Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). 3-Cs: As NCQA says, “Consistent, current and complete documentation in the medical record is an essential component of quality patient care.” Let’s go through these one at a time. Step 1: Be Consistent Establish a checklist of core requirements...

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