OIG
Office of Inspector General- established by the Dept. of Labor by the
Inspector General Act of 1978 to identify fraud and abuse of Medicare
part A and part B programs
MAC
Medicare Administrative Contractor - used by the OIG to process claims
for services rendered
Criteria for high quality documemtation
1. Legible
2. Reliable
3. Precise
4. Complete
5. Consistent
6. Clear
7. Timely
EBM
Evidence Based Medicine - the best scientific data a available for clinical
documentation
Two part theory for high quality clinical documentation is derived from
what
Legal/regulatory sources and peer reviewed research