Explain the contents of the medical record.

Review the following lecture:

  • Coding for Medical Necessity

Introduction:

In order to properly code a bill for medical necessity, it is important to understand the electronic medical record. This record contains information about the patient’s health both before and after the treatment and has the data needed to assure a payer that the treatment was necessary.

Tasks:

  • Explain the contents of the medical record.
  • Describe SOAP notes—subjective, objective, assessment, and plan.
  • Explain operative reports function in medical necessity coding.
  • Explain National and Local coverage determinations.

Submission Details:

  • Submit the report as a 5- to 10-page Microsoft Word document. Use APA standards for citations and references.
  • Cite a minimum of three outside peer-reviewed sources to support your assertions and save it as SU_HCM1201_W3_Project_LastName_FirstInitial.doc. Submit the report to the Submissions Area by the due date assigned.
  • Cite any sources using correct APA format on a separate pag
 

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