A guide to improving clinical documentation in a changing health environment.
Providing in-depth guidance for proper review of medical documentation in today's changing medical environment, this fourth edition is full of new content. New topics include electronic health records (EHR), ICD-10 coding, Health Information Management and many other issues essential for maintaining compliance.
Learn critical auditing fundamentals, read dozens of case studies, use the checkpoint exercises to test your knowledge, and download actual audit forms to help improve your process.
Features and Benefits:
- New content addresses EHRs, ICD-10 coding and more
- Downloadable forms. One copy of each audit form included in appendix, but all forms are downloadable from website.
- Case studies. Nine different specialties are featured with two case studies each, for 18 total case studies.
- Checkpoint exercises. Test your knowledge to confirm comprehension of new content.
NEW in this edition:
- Cases, chapters, direction for electronic health record (EHR) auditing
- Chapter on Clinical Documentation Improvement
- Downloadable audit forms
- Downloadable Audit Analysis Form and Summary Report
- Eighteen evaluation and management E/M case studies for the office setting
- Surgery audit cases>
- Other services audit cases (anesthesiology, radiology, PT and E/M other)
Physicians and administrators of medical practices, coding professionals, medical staff, medical office management companies, education market.