Mastering Documentation: Best Practices for Radiological Services Compliance

Event Materials (Key Required)

Course Description

Join us for an in-depth webinar designed to guide healthcare professionals through the essentials of documentation for radiological and diagnostic services. This session will walk you through the entire process, from understanding what constitutes a valid order and the creation of effective patient intake forms, to documenting medical necessity and ensuring that your records meet rigorous compliance requirements.

Our expert presenter will also cover common pitfalls, recent changes in regulatory requirements, and strategies for staying up to date with valid source documentation. Whether you’re new to the field or seeking to refine your processes, this webinar will provide practical insights and actionable tips for ensuring your radiological documentation is accurate, compliant, and audit ready.

Learning Objectives

• The key elements of a valid order
• How to document medical necessity beyond simply providing a diagnosis code
• Required documentation for images
• The training, qualifications, and equipment required for various diagnostic tests, including cardiovascular and neurological studies
• Frequency limitations, correct documentation of test interpretations, and signature requirements
• Overview of NCCI edits, proper use of modifiers, and how to avoid fragmented billing
• Understanding Local Coverage Determinations (LCDs) and their impact on compliance
• Effective strategies for maintaining thorough audit trails and responding to documentation requests

Areas Covered in the Session

• What Constitutes a Valid Order?
• The Benefits of a Patient Intake Form
• Documenting Medical Necessity – It’s more than a supporting diagnosis code
• Required Training and Qualifications for various Diagnostic Tests (e.g., Cardiovascular studies, neurological studies, etc.)
• Required Equipment for various diagnostic tests (e.g., Nerve Conduction, VNG)
• Frequency and Limitations for Certain Diagnostic Testing
• Documenting the Interpretation
  • The Indication
  • Documentation requirements for the most common tests
  • Signature Requirements & Timeliness
• The National Correct Coding Initiative (NCCI) edits (Unbundling)
• The Appropriate use of Modifiers
• Fragmented Billing
• Understanding Local Coverage Determination (LCDs)
• Learn More About It
• Live Q&A Session

Suggested Attendees

• Medical Coders – Beginners, Intermediate, and Advanced
• Medical Billers and Billing Staff
• Office Managers and Practice Managers
• Physicians and Nurses
• Non-Physician Practitioners
• Qualified Healthcare Professionals
• Healthcare Administrators
• Medical Auditors
• A/R Staff
• Revenue Cycle Staff
• Claim Handling Specialists
• Medical Officers
• Compliance Officers
• Hospital and Medical Staff
• Health Information Management (HIM) Professionals
• Billing Consultants
• Coding Supervisors
• Medical Records Technicians

About the Presenter

Mrs. Jacqueline Thelian is a Healthcare Consultant, Certified Professional Coder & Auditor, Subject Matter Expert and sought after educator and Author with over thirty years' experience in medical coding and business management. Her extensive experience includes physician practice management, coding/billing compliance and reimbursement issues and she has taught extensively in Academic Medical Centers, The Chubb Institute, Hospitals, private physician practices and has conducted a variety of seminars for numerous Medical Societies.   

She is also a AAPC Certified PMCC instructor for the PMCC (Professional Medical Coding wrriculum) Coding Certification Prep Course, and a Certified ICD-10 Expert Trainer. Her articles on clinical coding issues have been published in many popular healthcare publications.

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Additional Information

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to talk and hear clearly

Live Course Cancellation Policy: If for any reason Skillacquire need to cancel this program, Skillacquire will notify participants by email of the cancellation no less than 24 hours prior to the expected start time.

Can’t Listen Live? No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience.

For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

Purchase Order Form - Click Here to download PO form. 

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