American Academy of Professional Coders (AAPC) Practice Exam

What all services provided to a patient should be?

1. Optional based on the physician's discretion

2. Supported and documented in the medical record

3. Billed separately to the insurance carrier

4. Discussed with the patient verbally

The correct answer is: Supported and documented in the medical record

The correct choice highlights the importance of thorough documentation in a patient's medical record. In healthcare, every service provided to a patient must be properly supported by documentation to ensure continuity of care, enhance patient safety, and provide a clear account of the medical history and treatment received. This documentation serves several key purposes: 1. **Legal Protection**: It protects healthcare providers in the event of a dispute or malpractice claim, establishing a verified account of the care provided. 2. **Quality of Care**: Accurate documentation helps various healthcare providers understand the patient’s history and current treatment, facilitating informed decision-making. 3. **Billing and Reimbursement**: Properly documented services ensure that the billing process aligns with the care delivered, which is essential for reimbursement from insurance carriers. If services are documented, it supports claims processing and reduces the likelihood of denials. While the other choices pertain to aspects of patient care and billing processes, they do not emphasize the critical role of documentation in validating the services provided. Services may be billed or discussed but without proper documentation, there can be issues with insurance claims and continuity of care.