Name three top coding and documentation errors.
What will be an ideal response?
Answers will vary but may include: The chief complaint (the reason for the encounter) is missing. Assessment is not clearly documented. No diagnosis is given. The documentation is not initialed or signed. (e-signatures are accepted in EHRs). Tests ordered are not documented but are billed on the encounter form. Documentation of medication is not clear. The diagnosis is not always referenced correctly. Documentation is missing. Dictation is lost. The encounter form is incomplete or incorrect. Documentation is not complete, so the code has no record that an action was taken. Documentation is difficult to read. The service is downcoded one level; documentation supports a higher level of service. The service is upcoded one level; documentation does not support the level of service.
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