Practice Management and Regulatory Compliance
Core concepts
Know documentation, coding, and billing fundamentals: evaluation and management coding, procedure coding, medical necessity, and modifier use. Understand informed consent requirements, supervision and credentialing, and controlled-substance regulations including prescription monitoring and documentation standards.
Compliance themes
Medical necessity must be documented, not assumed. Prior authorization and payer rules affect procedure scheduling. Know anti-kickback and Stark considerations for referrals and ancillary services, and HIPAA obligations for records and communication.
Traps
- Billing a procedure without documented indication and failure of conservative care.
- Upcoding or unbundling that misrepresents services.
- Missing consent documentation for procedures.
- Overlooking state-specific controlled-substance rules.
Worked rule of thumb
If the note does not show the indication, the prior treatments, and the response, assume the claim is at risk. Documentation should let a reviewer reconstruct your reasoning without calling you.
Operations
Track outcomes and complications; quality data supports both patient care and payer relationships.