Medical Documentation

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 are 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.