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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. Drugs must also be identified and reported using a unique number, called the National Drug Code (NDC), which serves as a universal product identifier for the drugs.

Documentation, coding, charging, ... 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 ... causes of their errors and methods to prevent them.

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