Video instructions and help with filling out and completing Are Form 8453 S Authorization

Instructions and Help about Are Form 8453 S Authorization

Welcome to this presentation on your medical documentation matters this presentation is a comprehensive review of Medicaid documentation policies and procedures from evaluation and management e/m to discharge it includes a case study to demonstrate how complete and accurate documentation must be in order to receive reimbursement from Medicaid for medical services at the conclusion of this presentation participants will identify Medicaid medical documentation rules explain that services rendered must be well documented and that documentation lays the foundation for all coding and billing and describe the national impact of improper payments the goals of this presentation are for the participant to become familiar with medicaid medical documentation rules discover through a case study the importance of complete and detailed documentation as the foundation for coding billing and quality of care for the patient learn how poor documentation leads to improper payments which have a negative national impact on Medicaid during this presentation we will discuss the importance of medical documentation let's begin with a quick overview of Medicaid Medicaid is a unique program quite different from medicare medicare has nationwide laws and standards that every participating medical professional in any state must follow Medicaid programs on the other hand vary according to each state's statutes regulations and state plan within broad federal guidelines in addition each state has the option of developing and implementing medicaid waiver programs waiver program rules can also vary from state to state and even within the same States programs participating medical professionals must know and abide by the specific rules for each state where they practice and for each of the programs for which they furnish covered services state specific examples are cited in the presentation to illustrate the rules discussed during the presentation and may not be applicable in every state naturally as medical professionals you will want to be familiar with the nuances of the Medicaid program in the states where you furnish services if there are any questions regarding documentation visit your state's Medicaid website and search for the rules and regulation page or provide your handbook or by looking it up at Medicaid directors or on the National Association of Medicaid directors website during the presentation we will use a progressive case study to highlight important federal and state Medicaid documentation regulations and rules to illustrate these points we will follow a patient's course of treatment through several medical services and the respective medical professional types furnishing the services our patients treatment course begins with emergency transport and ends with his discharge from services let's get started by meeting our patient JK is a 52 year old male patient he is 6 feet tall and weighs 265 pounds JK currently smokes one pack of non filtered cigarettes per day and drinks approximately one case of beer per week he was diagnosed with hypertension high cholesterol and type 2 diabetes at age 40 his home medications include lisinopril simvastatin glipizide and metformin his blood pressure cholesterol and diabetes were well controlled until approximately two years ago JK is married and he and his wife have three children under age 17 he worked as a computer programmer for a small corporation for 18 years the corporation went out of business two and a half years ago since then he has been working part-time for a local retailer while he continues to search for full-time permanent employment in his field his wife has been working at their church as a part-time secretary for twenty years JK and his wife are in LA for health insurance benefits through their employers over the past two and a half years their standard of living has decreased and their savings has been depleted the entire family receives medical services through the state's Medicaid program JK struggles daily with his feelings of anger hopelessness and worthlessness he has become more withdrawn finds little joy in life and he refuses to engage in family activities even though he used to be the one to initiate them his agitation is growing and his family members avoid him before we get too deep into JK's case let's take a few moments and lay the foundation for why it is so important to document medical services medical professionals are in the business of helping their patients meeting ongoing patient needs such as furnishing and coordinating necessary medical services is impossible without documenting each patient encounter completely accurately and in a timely manner many providers have transitioned to electronic health records EHRs which can be an asset in meeting documentation goals documentation is often the communication tool used by and among medical professionals if a record is not properly documented with all relevant and important facts it can prevent the next medical professional from furnishing sufficient services the outcome can result in erratic or even dangerous treatment and cause unintended complications reasons for documenting medical services include meeting patient needs and complying with federal and state laws and regulations these laws require Medicaid medical professionals to maintain the records necessary to fully disclose the extent of services care and supplies furnish to beneficiaries as well as to support claims billed thereby reducing improper payments and the problems associated with them the purpose of EHRs is to improve healthcare quality safety and efficiency EHRs allow medical professionals a seamless approach for coordinating managing and making medical decisions they can help reduce paperwork eliminate duplicate tests and facilitate code assignment for billing however while EHRs can improve medical professional services medical professionals must be cautious when using them for example features like autofill and auto prompts can facilitate and improve medical professional documentation but they can also be misused cloning is a growing problem in healthcare cloning is copying and pasting previously recorded information from a prior note into a new note medical professionals may see a patient for the same thing repeatedly or for complications related to the same disease as a result many of the clinical notes may be similar however in