This unique manual shows what the medical record must contain for correct coding and billing of specific medical and diagnostic services and procedures. It provides coders and anyone concerned about coding with an auditor’s perspective on the clinical detail, regulatory instructions, and coding protocol needed for code assignment. Avoid the devastating effects of outside audits and reviews with this detailed coding tool.

Key Features and Benefits   

·        Optum Edge — Get online access to customizable audit worksheets. Protect your revenue-critical services and procedures.

·        Conduct skilled internal audits. Ensure proper reimbursement.

·        Differentiate between similar procedures. Compare and contrast seemingly similar, but different, procedures.

·        Completely updated for 2023 code set and regulatory changes.

·        Increase Revenue. Learn the appropriate way to report telehealth services.

·        Provides coders with an auditor’s perspective. Know the clinical detail, regulatory instructions, and coding best practices needed for code assignment.

·        Know what information needs to be in the medical record and on the claim form to capture appropriate reimbursement.

·        Know the key terms that need to be mentioned in the medical record to support code assignment.

·        See the medical conditions that are indicated for diagnostic, therapeutic, and surgical purposes.

·        Gain valuable code intelligence. Confirm correct code assignment.

·        Train your staff. This resource is thorough and can easily be used to train staff how to assign codes appropriately.

·        Correct modifier assignment. Modifier decision-making trees assist with assigning correct modifiers.

·        Supports Best Practices.