Medical Documentation, Billing, and Coding for the Advanced Practice Nurse

Carol Berger, Theresa Galakatos, Nina A. Zimmermann

• Publisher: Routledge
• Year: 2025
• eBook ISBN: 9781040264942
• Topic: Medicine
• Subtopic: Nursing

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.

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Authors
• Preface
• 1 The 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 Tools and Resources
• Index