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The best way to avoid payment and audit questions about your billing procedures is to make your claims are fully documented. Make sure, for instance, that:
• The medical record is complete and legible.
• Documentation of each patient encounter includes or references: the chief complaint and/or reason for the encounter and, as appropriate, relevant history, examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the health care professional.
• If not specifically documented, the reason for the encounter and/or chief complaint and the reason for ordering diagnostic and other ancillary services can be easily inferred.
• Past and present diagnoses and conditions, including those in the prenatal and intrapartum period that affect the newborn, are accessible to the treating and/or consulting physician.
• Appropriate health risk factors have been identified.
• The patient’s progress, response to and changes in treatment, planned follow-up care, and instructions and diagnosis are properly documented.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement are supported by the documentation.