Health Resources
Charting Tips to Capture Performed Services

If there is no claim indicating a service, a nurse must go to the provider office to conduct chart review. Documentation of the services in the chart is critical, not only to capture the clinical events, but to ensure correct billing and reimbursement.

MOST CRITICAL: history, results of testing and the components of exams.

• POSTPARTUM VISIT (Birth in last 8 weeks):
  
  A woman's visit with a PCP, NP or OB/Gyn within 8 weeks of a delivery should include a postpartum check. This is reimbursed above capitation:
  
  
  • The visit in the medical record should be labeled: "Postpartum visit/check"
  • Perform and document at least the following: BP, weight, breast exam and abdominal exam.
  
  
  Congratulations! You have just conducted a postpartum visit that will count toward the QARR measure. And if you code this as a postpartum visit, we won't even bother you for the chart.
  
  
  • ICD9 Diagnosis Codes: V24.1 or V24.2,
  • CPT Procedure Code: 59430
  
  
  
• CERVICAL CANCER SCREENING:
  
  Take the patient's history by asking the date of the last pap smear. If it is within 3 years, document the Year AND THE RESULT.
  
  Congratulations! You have just documented a valid pap test that will count toward the QARR measure.
  
  NOTE: You may perform a gyn exam and PAP test as a service that is reimbursed above capitation.
  
  
  • ICD9 Code: V76.2
  
  
  
• DIABETIC RETINAL EYE EXAM:
  
  When you receive a report of a dilated retinal exam within the past 2 years from the patient or the eye professional, document the test, the year and the result.
  
  Congratulations! You have just documented a valid eye exam that will count toward the QARR measure.
  
  

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