Please share a sample template for medical record documentation for implanting cardiac defibrillators. The medical record documentation needs to support the medical necessity of the procedure, clearly identify if Medicare criteria were met, and serve as a tool in determining if Medicare can be billed.
Answer: Please see this template tool for reference: Medical Record Documentation – Implant Report
This question was answered by: Curtis H. Bernstein, CHFP, CPA/ABV, ASA, CVA, principal, Pinnacle Healthcare Consulting, and a member of HFMA’s Colorado Chapter.
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