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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Click here for more sample CPC practice exam questions and answers with full rationale

Modifiers and progress notes

Hello!

Our office has always updated progress notes to match any time a modifier was added to a claim, but we have talked to a few other offices who have said that auditors do not care about whether the modifiers on the claim, are also reflected on the progress notes. They only care whether the services & documentation support the use of a modifier. Can anyone confirm whether or not if a modifier is added to a claim, it also needs to be added back to the note?

Thank you!

Medical Billing and Coding Forum

Progress Notes

Hi, I am currently a CRC coder and part of my job along with chart reviews is to re-write progress notes and to do addendums for the providers. I am not a clinician but my company requires us to re write plan of cares. We also have to mention stuff that was not mentioned. Example would be “continue to monitor salt intake”, “reduce sedative from whole pill to half of a pill” for sedative dependence, even though not mentioned and even though the provider did not specifically state that anywhere on the date of service or any other date of service. We are also told to use plan of care from previous visits to use for another date of service. I really don’t feel this is legal as a coder. Again, I am not a clinician and did not have a face to face encounter with the patient. My boss says that it’s okay to do this as long as the provider signs the notes and adds it to his chart. Is this legally okay? Please help.

Medical Billing and Coding Forum

Does every progress note stand alone

Does every progress need to stand alone ? I was taught that was the case but ,now I am being told that I can go anywhere in the patients chart to pull the information. For instance the patient is following up for an injury. The first vist is very detailed but the follow ups are not as detailed to assign the most specific ICD10 code. Can I use the details in the first note for a more specific code selection on my date of service ?

Medical Billing and Coding Forum

Progress Note Signatures

I am wondering if there is any hard rule about a physician signing off on a progress note before it’s complete.

I have an issue of receiving encounter forms and notes( it’s a paper-based clinic) that may have the encounter form fully filled out and signed, but missing dx, exam, and ros in the note. The notes are usually signed, though.

I may be searching it the wrong way, but I thought the signatures were meant to indicate the physician has authenticate what was done during the visit.

Medical Billing and Coding Forum

California medicaid (medi-cal) progress note — start / end time

Good morning,

Does anyone know where exactly that I could find any literature on clinical documentation requirements (verbatim) regarding the "start and end" time for Mental Health services (Individual / Family) rendered to a Medi-Cal (California Medicaid) Beneficiary?

Thank you in advance.

Medical Billing and Coding Forum

MA Health Review included in a Behavioral Health Med Mgmt progress note

We have several progress notes for Behavioral Health Med Mgmt that mistakenly included an MA Health Review copied over from a previous medical visit. Our EHR is not allowing the provider to delete this. Would this documentation now not meet requirements since the MA HR is present?

Medical Billing and Coding Forum

Educate Patients for Medical Progress

Patient education is the process by which health professionals and others impart information to patients that will alter their health behaviors or improve their health status. Education providers may include: physicians, registered dietitians, nurses, hospital discharge planners, medical social workers, psychologists, disease or disability advocacy groups, special interest groups, and pharmaceutical companies.

In the current age of information, pharmaceutical companies are in need for ideas to educate patients about new products and techniques to combat diseases and disorders that they suffer from, all in the effort to gain patient advocacy.

Educating a patient brings with it important value additions to brand perceptions as well. In addition to brand perception, other values of patient education includes improved understanding of medical condition, diagnosis, disease, or disability, better understanding of methods and means to manage multiple aspects of medical condition, improved self advocacy in deciding to act both independently from medical providers and in interdependence with them, increased compliance – effective communication and patient education increases patient motivation to comply, patient outcomes – patients more likely to respond well to their treatment plan – fewer complications, informed consent – patients feel you’ve provided the information they need, utilization – more effective use of medical services – fewer unnecessary phone calls and visits, satisfaction and referrals – Patients more likely to stay with your practice and refer other patients, risk management – lower risk of malpractice when patients have realistic expectations.

The bio-pharmaceutical marketplace continues to evolve as new medicines and technologies create valuable market opportunities. It’s in this competitive and challenging environment that organizations with new diabetes products are scrutinizing their strategies and tactics to support market education for patients. Marketing professionals in major pharmaceutical companies can now use benchmark reports that equip them with better ideas to improve patient education.

The benchmarking reports deal with the types and value of medical education and marketing tactics used to inform patient groups about new therapies. The reports include quantitative survey and interviews that helped identify patient education strategies and tactics that organizations use pre- and post-launch.

Qualitative and quantitative data is presented across a broad array of educational approaches, from public relations and new technologies to advocacy groups and early access plans.

Marketing executives can use this research to compare their patient education strategies and tactics with those of leading organizations.

Kirthy Shetty, Expert Author. More on Patient Education, Competitive Intelligence

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