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.