Medical Record Compliance Evaluation

How to Conduct a Medical Record Review - NCHA

https://www.ncha.org/wp-content/uploads/2018/11/ACDIS-White-Paper-How-to-Review-a-Medical-Record_2018.pdf

How to Conduct a Medical Record Review Appropriate reimbursement comes from the review’s capture of severity, clinical validation, coding accuracy, medical necessity, and quality outcomes. The record review should also track communication among CDI …

Best Practices to Achieve Clinical …

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

Check that E/M leveling narrates the true nature of the visit: Typical EHRs use boilerplate …

Evaluation and Management (E&M) Guidelines

https://www.compliance.cuimc.columbia.edu/compliance-standards/evaluation-and-management-e-m-guidelines

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, …

Using Peer Review for Self-Audits of Medical Record …

https://www.aafp.org/pubs/fpm/issues/2000/0400/p28.html

Peer review has been a mainstay of medical quality-assurance programs, and it provided a number of advantages in our self-audit process: Education. Reviewing other providers' …

Documentation Matters Toolkit | CMS

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

Home - Centers for Medicare & Medicaid Services | CMS

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

Home - Centers for Medicare & Medicaid Services | CMS

Ongoing Professional Practice Evaluation (OPPE)

https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/medical-staff-ms/000001500/

Compliance with core measures ^ Note: The manner in which such data is captured could represent either – or both – qualitative and quantitative information. Data …

HIPAA Retention Requirements - 2023 …

https://www.hipaajournal.com/hipaa-retention-requirements/

These generally fall into two categories – HIPAA medical records retention and HIPAA records retention requirements. The distinction between the two …

Your Records Management Compliance Audit Checklist

https://www.compliance.com/resources/records-management-compliance-checklist-developing-solid-compliance-records-management-program/

According to the U.S. Department of Health and Human Services Office of Inspector General (OIG), all effective healthcare compliance programs should implement some type …

Health Care Auditing and Monitoring Tools …

https://www.hcca-info.org/publications/books/AMTools-TOC

Proposed Corporate Compliance Annual Workplan Compliance Effectiveness Assessment and Evaluation Incident After-Action Report Physician Practices …