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Medical Record Auditor, 2nd Edition Changes At A Glance

Medical Record Auditor explains the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician's or outpatient office.

Key Features: · Documenation basics are reviewed, along with lessons on how to format chart notes, providing the reader with fundamental knowledge on how to maintain a compliant medical record. · Auditing tools are provided to aid in properly auditing medical records, along with instruction on analyzing and reporting the results of an audit. · Application exercises and a final examination are included to test the reader's comprehension of the material. · New to the Second Edition Extensive coverage of E/M documentation and chart audits, including discharge, case management and critical care services New chapter on auditing diagnostic radiology services for physician services with information on ICD-9-CM guidelines and insurance carrier policies for these services Expanded information on how to ensure medical records are compliant with current regulations New auditing tools and templates are provided to help you create your own auditing system CD-ROM to aid in medical record audit education o More than 110 auditing case examples, divided by specialty o Audit tools and report templates o Answer keys for test your knowledge questions o Powerpoint presentations outlining each chapter

Order #: OP301007 ISBN: 978-1-57947-884-1 Price: $74.95 AMA Member Price: $54.95

Medical Record Auditor, 2nd Edition - TABLE OF CONTENTS

Indicates new material for the 2nd edition

List of Figures List of Tables About the Author Preface Acknowledgments 1 The Medical Record Defining the Medical Record and the Role of the Medical Record Administrator Medical Record Accountability and Privacy and Release of Medical Record Information Components of the Medical Record Medical Record Entries The Patient Registration Form Financial Responsibility and Assignment of Benefits Consent for Treatment Medicare Lifetime Beneficiary Claim Authorization Patient Medical and Interval History Problem List and Medication Sheet Factors That Affect Learning (Learning Needs) Preventive Screening Advance Beneficiaty Notice (Medicare Waiver of Liability) Consent Form for Invasive Procedure Patient Encounters Laboratory Reports Report of Procedures Termination or Withdrawal of Treatment Immunization Records HIPAA Privacy Regulations Record Retention Key Terms Test Your Knowledge 2 Documentation Basics A Brief History of Medical Record Documentation Coding and Reimbursement The Purpose of Documentation The Medical Record as a Legal Document Progress and SOAP Notes Dictation vs Templates Checkpoint Exercises The Operative Report Documentation Guidelines How Documentation Affects the Coding Process Coding and Compliance Tips Key Terms Test Your Knowledge

3 Understanding the Evaluation and Management Codes Evaluation and Management Services Defined by the CPT Codebook Key Components and Contributory Factors Instructions for Selecting a Level of E/M Service Definitions of Key Components Evaluation and Management Documentation Guidelines From CMS Medical Record Documentation and Its Importance Medical Necessity and Diagnosis Coding (ICD-9-CM) for Physician Services Documentation Guidelines for Evaluation and Management Services 1995 vs 1997 Checkpoint Exercise 1 Checkpoint Exercise 2 Visits Dominated by Counseling and/or Coordination of Care Key Terms Test Your Knowledge Sources 4 Other Evaluation and Management Services Consultation Guidelines Reporting the Nursing Visit Code 99211 Preventive Medicine Services Observation Care Discharge Prolonged Physician Service With Direct (Face-to-Face) Patient Contact Discharge Services Nursing Facility Discharge Services Case Management Services Physician Standby Services Care Plan Oversight Critical Care Services Neonatal Critical Care Services Key Terms Test Your Knowledge Endnotes Sources 5 Compliance in the Medical Practice Coding and Reimbursement Privacy and Confidentiality The History of Compliance Fraud and Abuse Civil Monetary Penalties Law Federal False Claims Act Carrier Audits Benefits of a Compliance Program Compliance Plan Elements Designation of a Compliance Officer Education and Training Communication Auditing and Monitoring Disciplinary Action

Corrective Action Nonemployment or Nonretention of Sanctioned Individuals A Successful Compliance Program The National Correct Coding Initiative Key Terms Test Your Knowledge Sources 6 Chart Audit Process--The Medical Record Review The Audit Process Top Coding and Documentation Errors Auditing and Analyzing Your Medical Records Steps in the Audit Process Performing the Chart Audit The Chart Audit Process After the Audit Audit Tool Key Terms Test Your Knowledge 7 Auditing the Office Medical Record Chart Auditing: Step by Step Beginning the Audit Process Test Your Knowledge 8 Audit Reporting Mechanisms Analysis and Reporting Ongoing Monitoring Education and Training Corrective Action Plan What Triggers a Third-Party Payer Audit Key Terms Test Your Knowledge 9 The Surgical Medical Record Coding Based on Standard of Surgical Practice The Surgical Practice Surgery Coding Rules National Correct Coding Initiative (NCCI) Unbundling Separate Procedures Scope Procedures vs Open Procedures Diagnostic Services vs Therapeutic Services Add-on Codes Stand-Alone Codes and Indented Codes Beginning the Surgical Audit Process Checkpoint Exercise Key Terms Test Your Knowledge Endnotes Sources

10 Auditing Diagnostic Radiology Services for Physician Services Introduction The Anatomy of a Radiology Report ICD-9-CM Guidelines for Diagnostic Radiology Services Beginning the Radiology Audit Insurance Carrier Policies With Regard to Radiology Services The Radiology Audit Tool Test Your Knowledge Appendix A Appendix B Appendix C Appendix D Glossary Index CMS Exam Tables for 1997 Guidelines CMS Documentation Guidelines for 1995 and 1997 Audit Forms Valuable Web Sites

NOW INCLUDED ­ A CD-ROM aimed at enhancing education

CD-ROM Contents More than 110 Auditing Case Examples, Divided by Specialty Audit Tools and Report Templates Answer Keys for Test Your Knowledge Questions Powerpoint Presentations Outlining Each Chapter


American Medical Association

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