BC Advantage Magazine has published an article by Outsource Strategies International (OSI) titled “Key Strategies for Clinical Documentation Improvement in 2020”. The article appears in the July/August 2020 Issue of this reputable online medical billing and coding resource. The author, Meghann Drella, is an AAPC-certified coding professional on OSI’s expert team.
Maintaining documentation integrity while using automated EHR functions has become a major challenge for physicians. The Centers for Medicare & Medicaid Services (CMS) initiated its “Patients over Paperwork” strategy to simplify EHR documentation, but continues to focus on quality improvement to enhance delivery of care. Clear, accurate, concise documentation that tells the patient’s story and treatment plan to other caregivers is essential for the continuity of care.
OSI’s article brings together expert views on how healthcare providers can ensure documentation that validates services provided, reduces risks, and improves patient care.
It suggests five strategies for improving clinical documentation in 2020:
- Convey the patient’s story in detail
- Use the traditional SOAP documentation to add narrative to the record
- Supplement E/M templates with free-form text
- Judicious use of the EHR copy-paste function, and
- Document new findings and impressions
The report stresses the importance of being knowledgeable about ICD-10 official guidelines that address coding for uncertain diagnoses, with different rules for inpatient and outpatient coding. The article recommends that physicians conduct periodical self-audits of a select number of patient records to identify any issues and drive improvement.
OSI provides medical billing and coding services and practice management solutions for all medical specialties, from front office administrative management to back office coding, billing and collections. The company serves medical practices, dental practices, dentists and physicians. OSI’s team also specializes in insurance verifications and authorizations.
OSI’s team is especially excited that the July-August 2020 issue of BC Advantage Magazine features another of its articles, “Gastroparesis Awareness Month in August”.
Other OSI articles published by BC Advantage Magazine are: “Pharmacy Prior Authorization – Challenges and Solutions”, “Tick and Lyme Disease Diagnosis and Treatment”, “Viral Hepatitis – Types, Symptoms, and Diagnosis Codes” and “How to Code Screening and Diagnostic Colonoscopy”. Two reports by OSI were also featured in the magazine’s online medical coding article section: “Thanksgiving-Specific Foodborne Illnesses – Types, Symptoms, and ICD-10 Codes” and “ICD 10 Codes for some of the Worst Epidemics in the U.S”.