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You are here > Home > Reading Lists > Coding Books > Medical Record Auditor

Medical Record Auditor / Medical Record Chart Analyzer, 2nd Edition
American Medical Association, Deborah J Grider

Soft Cover: 366 pages with perforated answer key + bonus CD-ROM
Size: 8.5" x 11"
ISBN: 1579478840
9781579478841
AMA Press
August 2007
(click below for the very best currently available price for this title)

 

Medical Record Auditor includes medical record documentation with a systematic guide to the medical record review process for the physician's or outpatient office.

This edition of Medical Record Auditor expands on the first edition's foundation on the principles of medical record documentation and instructions on how to conduct a medical record audit in the physician's or outpatient office. This resource teaches the reader to review documentation basics and format chart notes, and gives guidelines and elements required for each level of service. Tools are provided to aid in properly auditing medical records, as well as instruction on analyzing and reporting results of an audit. Application exercises and a final examination are included to test the reader's comprehension of the material. New to this edition:

  • A CD-ROM containing all of the answers to the exercises, audit tools and report templates, auditing cases divided by specialty and PowerPoint presentations with summaries from each chapter

  • Extensive coverage of E/M documentation and chart audits

  • Guidelines for auditing radiology and operating room records

  • Information on how to ensure medical records are compliant with current regulations

CEUs included:

  • 10 CEUs from AHIMA: This book has been approved for 10 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association.

  • 6 CEUs from AAPC: This book has been approved for 6 continuing education units for use in fulfilling the continuing education requirements of the American Academy of Professional Coders.

Highlights include, learning objectives at the beginning of most chapters, medical chart review and coding tips, application exercises and a final examination to test documentation and auditing skills. This book will prepare the reader to accomplish the following objectives:

  • Understand the specifics about medical record chart requirements and the review process

  • Quick, Clear, Easy-to-Follow Chart Auditing Instructions, along with the Various Exam Cases and Operative Notes

  • Review formatting and documentation of chart notes

  • Learn to quickly analyze and summarize results for reporting and education

  • Analyze documentation guidelines and elements required for each level of service

  • Correctly audit the medical record using the handy tools provided

  • Understand how to develop, implement and monitor a quality improvement plan

  • Sample Audit Worksheets, Forms, Templates and Tables

  • Conduct reviews independently

  • Complete review of the Evaluation and Management Codes and Documentation Guidelines plus "How-to Rules" for HIPAA Compliance

Please remember that the government no longer allows a grace period for annual code sets. The new HIPAA Transaction and Code Set Rule requires providers to use national medical code sets that are valid at the time that a service is provided. ICD-9-CM code revisions become effective October 1st each year while CPT and HCPCS code revisions become effective January 1st. In order for you to meet this requirement, you must have the revised CPT, HCPCS, and ICD-9-CM codes in your possession before the implementation dates. The best way to do this is to order your code books early. Review current coding resources.

You may also be interested:  Coding Resources New!

(information provided by the publisher)

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