Abstracting Health Info Flashcards
What does EHR do?
assist providers with documentation and create medical information that can be used and
shared (Providers, Payers, and Organizations)
EHR stands for…
Electronic Health Record
Documentation for each encounter includes…
— Reason for encounter
— Hx (History), Physical Exam
— Diagnostic & Laboratory tests
— Tx (Treatment) plan to support each CPT, ICD-10-CM, or HCPCS reported on the claim
What will happen if tx is not documented?
It is considered NOT done according to the third-party payers.
What is the provider expected to do with the documentation?
They are expected to complete it in a timely manner and it should validate the appropriateness of the medical services or treatment.
What is a medical necessity?
It is the reasonable and appropriate services based on clinical standards per CMS (Centers for Medicare and Medicaid Services) and the OIG (Office of Inspector General).
Every PT encounter must include…
the reason for the encounter and support medical necessity
and if the documentation does not support medical necessity…
insurance payers can deny the claim, and services provided by the organization are not reimbursed
SOAP stands for…
Subjective, Objective, Assessment, and Plan
What includes in the Subjective?
— history of the condition using PT’s own words
— describes improvement or decline of the condition since the last tx
— states PT’s pain level
— explanation of any gaps in tx
— PT’s compliance with provider’s recommendation
Objective?
— are signs reported by MA / Provider, such as :
o Vital signs
o Physical examination findings
o Laboratory and other diagnostic data
o Results and documentation from other clinicians that have been reviewed and considered
Assessment?
diagnostic impression or working diagnoses based on the subjective complaints and objective findings
Plan? and its examples
procedure or plan for tx including tx frequency, duration and expected outcomes and goals of the tx
examples are medications, referrals, and patient education or counseling
