In Coding
Mar 21st, 2018
Acronyms and abbreviations are acceptable in the medical record if they are commonly recognized. If a practice uses terminology that is not industry standard, it must maintain a list of the abbreviations with definitions and how they are used, and should submit this documentation anytime an audit is done. Because confusing abbreviations can create problems with ...
Apr 1st, 2013
By Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS As a physician auditor, I spend much of my time educating clinicians on proper documentation. This involves explaining and interpreting coding and compliance guidelines. When providing such guidance, the most common reply I hear from providers is, “I want it in writing.” An auditing ...