Discussion Post: The Importance of Clinical Documentation
What is the outcome when a clinical auditor is reviewing E&M code calculations and the unethical and illegal pitfalls of up-coding by means that contradict regulatory guidelines? In 250-300 words, discuss how and why a physician and medical coder should adhere to the coding conventions, official coding guidelines, rules and assigned codes that are clearly supported by clinical documentation in the health record. Include examples of where this can occur so a physician or entity, maximize their payments and the ramifications if discovered in a clinical documentation audit?
The response must include a reference list. One-inch margins, double-space, Using Times New Roman 12 pnt font and APA style of writing and citations.