Better Medical Documentation Can Improve Your Reimbursement Benefits

by | Published on Oct 12, 2013 | Medical Billing

Medical Documentation
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Partnering with experienced medical coding company can go a long way in improving the revenues of your practice. You need to establish proper communication with your medical coding team to assure proper documentation which is crucial to maximize your reimbursement benefits. Here are some tips to ensure accurate documentation:

  • Provide detailed procedure specifications – When it comes to making surgical notes, you should document the exact details such as identifying the surgical approach, procedures performed, and any unusual occurrence during the surgery. For instance, ICD-10 has greatly increased the specificity for selecting codes. While some codes are based on laterality, for instance, right ear, left ear, bilateral ear and unspecified ear, other codes are selected on the basis of whether the condition is a first occurrence or a re-occurrence. So if you perform a complicated surgical procedure, you should specify every detail in your surgical notes so that the correct codes can be assigned.
  • Beware of EHR documentation shortcuts – EHRs have simplified documentation and help physicians save time by cutting and pasting information from a previous patient or selecting from a drop-down menu. Such shortcuts can be justified to some extent, but you should remember that progress notes are important to justify continued hospitalization. Insurance companies would pay only if they are convinced that the services were medically necessary and your notes should indicate this clearly.
  • Documentation of time – Many codes are based on the time the physician spends with the patient as for instance, critical care which comes under time-based codes (99291-99292). For codes based on time, you have to document the total time spent which includes the time on the face to face with the patient and floor time with the patient and/or family member, time spent on reviewing diagnostic tests, and discussions with other providers involved in the treatment. A description or summary of the counseling/ coordination of care has to be provided with the claim along with the specific time spent on these activities.

Paying attention to these aspects in medical documentation will help ensure enhanced reimbursement and better patient care.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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