1st Edition
Medical Documentation, Billing and Coding for the Advanced Practice Nurse
Written specifically for student and new nurse practitioners, this guide presents the essentials of how to document, code, bill, and get reimbursed for services provided in practice.
Coding is a core skill that requires practice and a nurse practitioner is responsible for the accuracy of codes submitted on a claim form. This book covers the context and background for billing and coding, how to document correctly, the 2021/2023 evaluation and management coding changes, specialty services, the legal implications of coding and medical necessity. Using a read it, see it, do it approach as a learning strategy, the book includes case studies from a range of inpatient and outpatient settings and practice exercises to try out your skills. Resources linked to updates on billing and coding rules will be provided as an appendix to ensure the content can be applicable long term.
This text is an invaluable resource for students and nurse practitioners new to coding and billing.
1. History of Medicare and Medicaid
2. General Principles of Medical Record Documentation
3. Documentation
4. Evaluation and Management Coding Changes 2021/2023
5. Specialty Services
6. Examples of Documentation with Coding
7. Additional Services
8. Legal Implications of Coding and Billing
9. Medical Necessity
10. Practice Coding
11. Practice Answers
12. Resources
Biography
Dr. Carol Berger is an inspiring dedicated health professional and teacher. Credentials include Doctor of Nursing Practice (DNP), Master of Science in Nursing (MSN), and Certified Family Nurse Practitioner. She has devoted her life to serving her patients and students. Currently serving as an Associate Professor of Nursing at the Catherine McAuley School of Nursing within Maryville University’s esteemed Myrtle E. And Earl E. Walker College of Health Professions, Dr. Berger brings with her life experience as a nurse and provider to inspire and educate the rising generation.
Dr. Theresa Galakatos is a dynamic and accomplished healthcare professional who has established herself as a prominent figure in the nursing and academic spheres. With an impressive array of credentials, including a Doctor of Nursing Practice (DNP), a Doctor of Philosophy in Nursing (Ph.D.), a Master of Social Work (MSW), and multiple Master of Science in Nursing (MSN) degrees, she stands as a true exemplar of lifelong learning and dedication to the field. Currently serving as an Associate Professor of Nursing at the Catherine McAuley School of Nursing within Maryville University's esteemed Myrtle E. and Earl E. Walker College of Health Professions, Dr. Galakatos brings her wealth of knowledge and practical experience to inspire and educate the next generation of healthcare professionals.
Dr. Nina Zimmermann is an Assistant Professor of Nursing at Maryville University and an adult nurse practitioner (NP). In 2019, she earned her doctorate in education at Maryville University. Dr. Zimmermann has 15 years of advanced practice nursing and 13 years of nurse practitioner education experience and She is a board-certified adult primary care NP with a primary care clinical practice in St. Louis and Maryville Health and Wellness Clinic. She has published and presented in her research areas of adherence to clinical practice guidelines for asthma, asthma patient and family education, innovative and active-learning online teaching strategies, NP students’ learning how to document a patient encounter, and the use of infographics to promote nursing students’ learning of their patient’s culture and diversity. She is a co-host of the Nurse Practitioners Changing Practice podcast and website, https://npschangingpractice.com/
