These are some of the top coding/documenation errors:
-Documentation does not support the level of service
-Chief complaint is missing
-Assessment is not always clearly documented
-Documentation is not signed
-Tests ordered are not listed in the documentation but are billed
-Documentation of meds are not always clear
-Dx is not referenced correctly or incorrect linkage
-Missing documentation/forms missing in chart
-Encounter forms are not available
-Documentation is not complete or hard to read
-Improper use of CPT codes
These are some errors that auditors look for. Anyone else?
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