Documentation and Coding

Abstract

The provision of care to residents of long-term care facilities presents different complexities in documentation and coding for both physician and practitioner services than those provided in the office or hospital setting. Proper documentation of the care provided and use of the appropriate billing code is essential to receiving appropriate reimbursement for rendered services. Practitioner familiarity with a glossary of common terms (see Figure 14.1) is critical to ensure accurate documentation, coding, and billing.