Medical Record Guidelines

Question 1

What do encounters need?

Answer 1

Clear date of service
patient name with a second identifier providers name with credential

Question 2

It is appropriate to code legible sections of the note when other parts of the note are illegible.

Answer 2

True—per Aetna consolidated guideline code, legible portion, and skip the parts that are illegible

Question 3

Acceptable documentation must be clear, concise, consistent, and

Answer 3

Legible

Question 4

We can code vaccination encounters if rendered by an approved provider

Answer 4

True— vaccination encounters are treated as normal encounters if an approved provider such as an MD performed the service