Wiki Abbreviation use

kumeena

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In Medical primary clinic patients diagnosed with hyperlipidemia and can doctor write HLD? Is it acceptable for CMS audting?

patients come to the clinic (nursing visit for FBS/BP check) and the doctor bill 99211 and instead of writing the diagnosis doctor writes FS/BP numbers and the medication information (RX or dosage is taken by patient or any other modifcation) Is it documentation Ok for billing?

Thank you
 
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I'm not sure what CMS auditing would say because I've never been through one, but an indepedent auditing firm once told us at a place that I worked for that we needed to have an approved abbreviation listing for our agency in order for abbreviations to "stand" in an audit. We pulled many of the more common ones and chose not to use ones that could easily be mistaken for other terms, especially medications.
 
List of acceptable abbreviations

I agree. You need a list of approved abbreviations - and what they stand for - for your practice.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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