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Documentation, coding, charging, and billing for ...

documentation , coding , charging , and billing for medications identifying risks and internal audit focus areas 2 documentation , coding , charging , and billing for medications identifying risks and internal audit focus areas 1 IntroductionMedications administered to patients in both the inpatient and outpatient settings must be properly documented to support the coding and billing requirements for pharmaceutical drugs. The administration of drugs is documented by clinicians in the patient s medication administration record, a component of the patient s permanent medical record. Medical coders and billers abstract the quantity and type of drugs administered from the medical record, assign the appropriate codes, and create a claim to be submitted for reimbursement.

Documentation, coding, charging, and billing for medications Identifying risks and internal audit focus areas 3 Pharmacy purchasing data Some key risks One of many risks facing the pharmacy department is the proper documentation and tracking of both used and unused medications. If a drug has been discontinued or

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  Identifying, Coding, Internal, Risks, Documentation, Medication, Charging, Billing, Billing and, And billing for medications identifying risks and internal

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