Guide to Clinical Validation, Documentation and Coding -- 2015 by Optum360
Guide Clinical Validation Documentation Coding by Optum360
There has been much discussion recently regarding clinical validation and with good reason. Every patient, whether in the hospital or the myriad of other venues where one presents for care, has a right to receive high quality health care with a medical record that outlines this process — this is a point all can agree upon. Once the patient leaves the care of the provider, the only true and legal piece of communication that remains is the medical record. It is the responsibility of every person who enters information in the medical record to ensure it is precise and complete. As the record is reviewed, both gap identification and clinical validation of the documentation are being performed.
Now there is a unique new resource that provides the clinical criteria necessary for code assignment. This new tool also describes the clinical documentation.
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Be the first to write a review. This new tool also describes the clinical documentation needed for determining if the condition is a complication, or when a medical condition should be coded as an additional diagnosis. Now coders, utilization review staff and HIM managers can systematically evaluate the clinical criteria that influence code assignments and patient care. Read Full Description. Order by purchase order. This is a concise, reliable, and easy-to-follow tool for those problematic diagnoses and PCS inpatient procedures that are most often questioned by payers.
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