Friday, June 13, 2008

Medicare supporting documentation

When documenting patient charts please make sure you take these into consideration:

  1. Documentation needs to support the service billed, the level of service and the medical necessity of the service
  2. Documentation needs to be clear, concise, complete and LEGIBLE
  3. If someone else where to evaluate the document they should be able to come to identify the same service performed and the reason why.

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