Medical Record Chart Analyzer: Documentation Rules and Rationales with Exercise

From The Critics

Reviewer: LouAnn Schraffenberger, MBA, RHIA, CCS, CCS-P(Univ of Illinois at Chicago School of Biomed & Health Info Mgmt)
Description: This is an introduction to the principles of medical record documentation and how to conduct a medical record content review for a physician's office record. While the book focuses on documentation to support Current Procedural Terminology (CPT) coding of services and procedures, the documentation of medical diagnoses is discussed to support medical necessity.
Purpose: The book is intended to prepare the reader to accomplish the following objectives: (1) Understand the content of the medical record; (2) Review the basics of documentation and formatting of record notes; (3) review the documentation guidelines and elements required for each level of service; (4) understand the record review process or auditing; (5) properly audit the medical record using the tools provided; (6) analyze and report results of the medical record review or audit; (7) develop a mechanism for reporting and education; and (8) understand the importance of developing a performance improvement plan.
Audience: According to the author, the book is designed to be used as a book in a community college, career college or vocational school to train medical office coders, medical insurance specialists, and related healthcare staff members. The book may also be used as an independent study tool for any healthcare practitioner interested in documentation auditing to support coding and billing. The author is a physician-based coder credentialed by the AAPC and AHIMA and a certified complicance professional. The author is also an experienced educator of medical assistants and coders.
Features: The book contains 11 chapters, four appendixes, and an answer key. Two chapters examine medical record content and documentation principles. Two chapters examine the use of CPT Evaluation and Management (E&M) codes and Medicare's documentation guidelines. One chapter presents compliance issues for the medical practice. The six remaining chapters describe the medical record review or audit process. The appendixes include the Medicare E&M guidelines from 1995 and 1997. Numerous forms are included such as audit, insurance, and claim forms.
Assessment: This is a solid book to introduce and promote understanding of physician office record content and its relationship to coding, reimbursement, and compliance. Each chapter's learning objectives and exercises promote the learning process. Personally, I would have used a different title for the book. In healthcare, the term "chart" has been replaced with "record" but both are in the title and it does not explain the goal of the book as a tool to promote understanding of record content in order to code properly. Instructors in medical coding programs should take a look at this book for a record content and/or compliance course. The book is more about auditing than record content but it does explain both well.

3 Stars from Doody