Medical Documentation Compliance

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Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse. Documentation Matters Fact Sheet for Medical …

ICN909160 | CMS - Centers for Medicare & Medicaid …

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909160

Provider Compliance Title Complying With Medical Record Documentation Requirements Format Fact Sheet ICN: 909160 Publication Description: Learn about …

Documentation Matters Fact Sheet for Medical …

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Resource-Library/documentation-matters-fact-sheet-medical-professionals

Documentation. Description. This resource is part of the Documentation Matters toolkit, which educates providers about the importance of compliance in …

Complying With Medical Record Documentation …

https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet

Download the Guidance Document. Final. Issued by: Centers for Medicare & Medicaid Services (CMS) Issue Date: April 01, 2017. DISCLAIMER: The contents of this …

Best Practices to Achieve Clinical …

https://www.aapc.com/blog/48544-best-practices-to-achieve-clinical-documentation-improvement/

Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best …

What Is Clinical Documentation Improvement (CDI)?

https://www.aapc.com/clinical-documentation-improvement/

A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record …

What Is Healthcare Compliance? All You Need to Know …

https://www.aapc.com/healthcare-compliance/healthcare-compliance.aspx

Healthcare compliance is the formal name given to proactive tasks to prevent fraud, waste, or abuse within a healthcare entity. A compliance program is the active, …

Guidelines for Medical Record Documentation

https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf

10. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints. 11. …

5 Best Practices for Medical Documentation - Clinical Advisor

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

Examples of such documentation include “Follow up in 1 month regarding change in losartan dosage and then resume routine follow-up every 3 months” or “will …

Simplifying Documentation Requirements - Past …

https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/simplifying-documentation-requirements/simplifying-documentation-requirements-past-changes

Explained that a signature and date is acceptable verification of a medical student’s documentation of an E&M visit performed by a physician. BEFORE: As of January 1, …

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