This unique manual shows what the medical record must contain for correct coding and billing of specific medical and diagnostic services and procedures. It provides coders and anyone concerned about coding with an auditor’s perspective on the clinical detail, regulatory instructions, and coding protocol needed for code assignment. Avoid the devastating effects of outside audits and reviews with this detailed coding tool.
Key Features and Benefits
• Optum360 Edge—Get online access to customizable audit worksheets. Protect your revenue critical services and procedures.
• Conduct skilled internal audits. Ensure proper reimbursement.
• Differentiate between similar procedures. Compare and contrast seemingly similar, but different, procedures.
• Completely updated for code set and regulatory changes.
• Provides coders with an auditor’s perspective. Know the clinical detail, regulatory instructions, and coding protocol needed for code assignment, by individual code and code groupings.
• Know what information needs to be in the medical record and on the claim form to capture appropriate reimbursement.
• Know the key terms that need to be mentioned in the medical record. Support code assignment.
• See the medical conditions that are indicated for diagnostic and therapeutic purposes.
• Get valuable code intelligence. Confirm correct code assignment.