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

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.

Carol Berger is an inspiring, dedicated health professional and teacher. Her credentials include Doctor of Nursing Practice (DNP), Master of Science in Nursing (MSN), and Certified Family Nurse Practitioner. She has devoted her life to serving her patients and students. Currently serving as an Associate Professor of Nursing at the Catherine McAuley School of Nursing within Maryville University's esteemed Myrtle E. and Earl E. Walker College of Health Professions, Dr. Berger brings her life experience as a nurse and provider to inspire and educate the rising generation. She is a co-creator of the website http://simplyaprn.com which contains different lectures on pathophysiology and pharmacology as well as interactive games to reinforce learning concepts for the rising generation of nursing students, as well as co-host of the NP Changing Practice podcast. Theresa Galakatos is a dynamic and accomplished healthcare professional who has established herself as a prominent figure in the nursing and academic spheres. With an impressive array of credentials, including a Doctor of Nursing Practice (DNP), a Doctor of Philosophy in Nursing (Ph.D.), a Master of Social Work (MSW), and multiple Master of Science in Nursing (MSN) degrees, she stands as a true exemplar of lifelong learning and dedication to the field. Currently serving as an Associate Professor of Nursing at the Catherine McAuley School of Nursing within Maryville University's esteemed Myrtle E. and Earl E. Walker College of Health Professions, Dr. Galakatos brings her wealth of knowledge and practical experience to inspire and educate the next generation of healthcare professionals. Nina A. Zimmermann is an influential nursing professor and experienced adult gerontology primary care nurse practitioner. She earned her Master of Science in Nursing (MSN) in Nursing Education, a Post-Masters Certificate in Adult-Gerontology Primary Care Nurse Practitioner, and her Doctorate in Education (EdD). She is considered an expert in nursing education and primary care practice. Her current academic position is as Associate Professor of Nursing at the Catherine McAuley School of Nursing within Maryville University's esteemed Myrtle E. and Earl E. Walker College of Health Professions. Dr. Zimmerman contributes her advanced nursing practice experience and nursing education of nurse practitioners to this textbook and to future primary care nurse practitioners.

1. History of Medicare and Medicaid 2. General Principles of Medical Record Documentation 3. Documentation 4. The 2021/2023 Evaluation and Management Coding Changes 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. Resources