medical records

  1. R

    Wiki Eye Exam Documentation

    I conduct medical record reviews (chart reviews) for an External Quality Review Organization. Their Encounter Data Validation task requires providers to submit records and my job is to check and make sure the coding/documentation for the encounter matches the claim that was sent to the MCO...
  2. E

    Wiki Timely Documentation (signature) within 90 days

    As stated in Chapter 2 of our Compliance studies, under Responding to detected offenses and developing corrective action initiatives, type of issues, bullet 2- states that medical records are to be signed/completed within 90 days. I can not find any reference to this statement. I have a...
  3. Walker22

    Wiki Software Vendor withholding access to medical records

    My employer recently (Sept 2019) switched EHR vendors. Consequently, we no longer have login access to the old software. We recently had a legal request for a copy of the medical records for a patient we saw one time back in 2018. We contacted the old vendor to see about getting a copy, and we...
  4. D

    Wiki Unspecified codes and medical records

    Hello. Relatively new to the coding world and experiencing some confusion on our team regarding the use of unspecified codes that have previously been used in the patient's past medical record/history as a specified version. (Example: Unspecified A-Fib for this encounter, but the pt has...
  5. P

    Wiki Medical Records requests

    I am very new to Medical Billing and Coding and recently started a new job. A request came in from an insurance company asking for medical records on a patient for a very wide date range. It stated they were looking for pre-existing conditions. My question is can they do this, request medical...
  6. K

    Wiki seeing patients without ID

    Where I work we are allowed to check in patients without picture id providing they are cash pay. It concerns me that we are creating medical records and writing prescriptions for these patients. Do I have reason to be concerned or should I just relax?
  7. N

    Wiki New at the industry need advice

    Hi! I am a makeup artist and a mom of a smart, vibrant boy. In the search for a better life for my son, I started a medical records certificate. I am three classes away from completing my Medical Records Certificate. I have to admit that now that I can see the end of this journey I am...
  8. K

    Wiki What constitutes a patients medical record?

    At the clinic where I work when vaccines are given they are recorded online in a state registry but nowhere within our EMR. I have been told that the state registry is a part of the patients medical record and therefore that is sufficient documentation. But since we don't maintain that registry...
  9. K

    Wiki BCBS Medical Necessity Denial

    Hi All! Hoping someone can help me out. We have been put on prepayment review for BCBS which means we need to submit medical records for all codes billed with a Transvaginal sonogram. We have done so for all patients (2-3 page E&M, 2-3 page Ultrasound report). BCBS has constantly come back on...
  10. D

    Wiki General Chart Review Question

    Hello all. I am a new AAPC member working on my CRC certification. I work for a start up health plan in NYC and we are working on conducting our first round of chart reviews for risk adjustment. If a health plan has medical records and identifies discrepancies in their HCCs (assuming the...
  11. T

    Wiki Herceptin

    Is anyone getting requests for documentation for Herceptin, we send what they are requesting and Medicare denies it. It meets guidelines i'm just not sure what were doing wrong. Has anyone experienced this?
  12. K

    Wiki Shared Medical Record

    Hello - I am in need of some expert help. I need to clarify the meaning of "shared medical record". Here is a scenario: A group of several entities/facilities enter data to the same electronic record system. All entities involved have access to the whole system. Would this be considered a shared...