Medical Economics: Cracking the code

You can obtain reimbursement at a higher level and overcome your fears of being audited by thoroughly and correctly documenting the care you provide to your patients. AAPC’s Director of Product Development Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, was recently interviewed for a Medical Economics article that offers strategies for selecting appropriate E/M levels and documenting patient care. Ms. Jimenez suggests that good medical documentation should answer the following questions:

Anesthesia and Pain Management CANPC

  • Why is the patient there that day?
  • What is the patient describing?
  • What type of exam(s) is/are being performed on the patient?
  • What tests are being ordered, and why?
  • If the patient has any chronic illnesses, what is your assessment of them?
  • Are the patient’s laboratory test results within the acceptable ranges for managing those diseases?
  • Since the last visit, how has the patient been adhering to his or her medication regimen?

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