Importance of Complete Medical Documentation for Proper Billing and Reimbursement

Documentation Presentation By: Joanne Taraskiewicz

Examples from the patient records that are properly documented 411057 1. 2. 3. C50.411 for Malignant neoplasm of upper quadrant of right breast Estrogen Receptor negative status [ER-] Partial Mastectomy 410092 1. Essential hypertension 2. Type 2 Diabetes Mellitus 3. Unspecified Asthma 4. Hypothyroidism 5. GERD

Examples from the patient records that are properly documented 410198 1. Epidermal Cyst 2. Hypothyroidism 3. Repair of wound on face 410296 1. 2. 3. 4. 5. 6. 7. Encounter for dental examination and cleaning with abnormal findings Unspecified intellectual disabilities Autistic disorder Generalized Epilepsy Periapical abscess without sinus Amalgam one surface, primary or permanent Comprehensive periodontal evaluation new or established patient

Examples from patient records that are not accurate or complete information 410057 1. 2. Adjnt tis trnsfr/reagmt any area 30.160 sq cm They talk about an MRI not an ultrasound 410092 1. 2. It talks about malignant neoplasm of ascending colon It does not mention anything in history for hypercholesterolemia 410198 1. It is on the face and the excision code is for except on the face 410296 1. 2. It talks about dyslipidemia I did not read about an extraction

The importance of proper medical documentation Proper documentation stops claims from getting denied so that the patient will get a bill, the physician will not get paid for the services rendered and the company will not get their reimbursement for the procedure performed. Proper documentation will allow the coders to have the correct information about the procedure to be able to assign the proper codes.

Suggestions to ensure physician documentation is complete and accurate Define professional standards: The first step toward better clinical documentation is for a practice to create guidelines for note taking that align with industry standards. The American College of Physicians (ACP) recently released a report that detailed various ways that medical providers can improve their documentation. (McCathy, Kevin, 2015) Expand education Some practices may assume that new staff members understand documentation standards, but knowledge of these skills can always be improved. The Healthcare Financial Management Association explained that healthcare organizations will benefit from providing structured training on clinical documentation to new and existing employees. (McCathy, Kevin, 2015)

Suggestions to ensure physician documentation is complete and accurate Create peer-to-peer support systems Nominating a physician leader to spearhead documentation improvements is often a good way to reduce reliance on EHR vendors or third-party trainers. When there is a staff member who knows the ins and outs of best documentation practices, a peer-to-peer support system will be created. This individual should be dedicated to the cause and able to keep up with new developments in note taking. (McCathy, Kevin, 2015) Review information It may seem like a no brainer but taking a few minutes to review the accuracy of past documentation can be extremely beneficial in improving overall accuracy of EHRs. When physicians take time to quickly validate notes with patients, they can catch small errors that may still be on file. (McCathy, Kevin, 2015)

Suggestions to ensure physician documentation is complete and accurate Allow patients greater access to EHRs It is inevitable that physicians will make documentation mistakes from time to time, and who is better qualified to catch these errors than patients? The ACP report noted that when patients are able to review their medical records, they often find inaccuracies that could be substantial in optimizing treatment. By allowing patients to view their EHRs via online portals, practices may be able to improve their documentation and reap the benefits associated with thorough and accurate notes. (McCathy, Kevin, 2015)

References McCathy, Kevin. (2015, January 22). 5 tips to improve clinical documentation. Retrieved from https://nuemd.com/news/2015/01/22/5-tips-improve-clinical-documentation