Are You Documenting Prescription Drug Management Properly?

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In clinical settings, proper documentation of prescription drug management is essential for ensuring patient safety, compliance with regulatory standards, and accurate billing. Additionally, understanding the differences between prescription and over-the-counter (OTC) medications is crucial for effective medication management. Here we outline the documentation requirements for prescription drug management and highlight the key differences between prescription and OTC medications. Documentation Requirements for Prescription Drug Management According to the AMA, appropriate documentation of prescription drug management involves…

Ensuring Your Moderate Level of Service Meets the Coding Criteria

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Does your documentation match your moderate level of service billed?  With the changes implemented by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS), it is very important to make sure your documentation matches the level of service you are billing.  Many providers are finding themselves billing more moderate level of service visits now than they did previously under the old guidelines.   Criteria for Code Selection To achieve a moderate level of service, at…

Documenting Substance Use Treatment: A Pivotal Junction

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Accurate documentation is essential for ensuring proper treatment, reimbursement, and overall quality of care. For substance use treatment, this is particularly important. The challenges of documenting client visits for substance use involve not only rigor but also a solid comprehension of the intricacies involved in addiction treatment and the individuals involved. In this blog, we will explore the importance of accurate documentation in substance use treatment, the influence on client outcomes, and how clinicians can…