Documentation must be legible and in English. Consider transcribing your notes if your handwriting is not legible. You may have an assistant take notes for you.
Medicare does not prescribe specific forms. You may use the forms that work for you. Some sample forms are in the Library section of this course.
The important issue is to clearly address all the documentation requirements found in the policy. Do not leave blanks, or "holes," in your documentation. If something in the policy is not addressed or not applicable, indicate so. The best form is the one that is completely filled out and addresses all the points in the policy.
Throughout the rest of this course, examples are given for a fictitious patient. The examples are outlined in a blue text box.
The examples given in this course are for education purposes only and do not represent actual claim information.