Documentation Matters

60 minutes

This course is not accredited.

Meeting ongoing patient needs, such as furnishing and coordinating medically necessary medical services, is impossible without documenting each patient encounter completely, accurately, and promptly. Documentation is often the communication tool used by and between medical professionals. Records not properly documented with all relevant and important facts can prevent the next provider from furnishing sufficient services or supporting medical necessity for the claim(s) submitted. The outcome can result in erratic or even dangerous treatment and cause unintended complications. While meeting patient needs is the most important reason for documenting services, it is not the only one. Another reason for reporting medical services is compliance with federal and state laws. These laws require practitioners to maintain the records necessary to “fully disclose the extent of the services,” care, and supplies furnished to patients and support claims billed. This session will cover an overview of medical necessity and why complete and accurate documentation matters.

Learning Objectives:

• Define the term 'Medical Necessity' as related to Clinical Documentation
• Prioritize the importance of coding and documentation issues
• List two or more consequences of poor documentation of medical necessity
• Describe at least one strategy to improve documentation to support medical necessity

Note: This is a recording of a live event.

Reminder: You have 30 days to complete the course from the day you register. Access expires after the 30 days.

Christine Banks, RHIA, CPC, CPCO

Consultant

KZA

Christine Banks has more than 32 years of experience in health information management, including four years in coding education and quality assurance and 26 years of surgical coding experience in orthopedic surgery, having worked at the Orthopedic practice of Massachusetts General Hospital in Boston prior to joining the KZA team.

Christine is a highly sought-after and nationally recognized speaker for prominent associations such as the Orthopedic Trauma Association (OTA), the American Society for Surgery of the Hand (ASSH), and the American Academy of Orthopaedic Surgeons (AAOS).

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Documentation Matters

Christine Banks, RHIA, CPC, CPCO

Consultant

KZA

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