When Documentation Does NOT Support the Level of Service Provided

question 86

Short Answer

When documentation does NOT support the level of service provided, and a lower-level code should have been selected, this practice is known as ________.

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Definitions:

Provider's Statement

A formal document or declaration issued by a healthcare provider detailing a patient's condition, treatment, and recommendations.

Main Term

The primary or most important word or phrase used in documentation, indexing, or referencing to identify a concept, subject, or object.

Encounter Form

A document used in healthcare settings to capture details about a patient's visit, including services provided, diagnosis, and billing information.

Clinical Medical Assistant

A healthcare professional who performs administrative and clinical tasks in clinics and medical offices to support patient care.