Outsource Strategies International is delighted to announce that BC Advantage, a highly acclaimed CEU approved national online healthcare publication, has published its article titled “Key Strategies for Improving Clinical Documentation in 2020”. Written by Meghann Drella, CPC, OSI’s Senior Solutions Manager, Practice and Revenue Cycle Management, Healthcare Division, the article appears in BC Advantage Magazine’s July/August 2020 – ISSUE 15-4. Meghann is an AAPC-certified coding professional on OSI’s expert team.
Maintaining documentation integrity is a major challenge faced by physicians while using automated EHR functions. Though electronic documentation is designed to increase both the quality and the utility of clinical documentation, it has resulted in large volumes of data and repetitive information. If the information presented in the clinical documentation does not provide a complete and accurate picture of the care received by a patient or does not support the billing codes, claims may be denied. Therefore, it is critical to ensure accurate, comprehensive, trustworthy, and timely clinical documentation to validate services provided, reduce risks, and improve patient care.
OSI’s article shares expert views on how healthcare providers can ensure documentation that validates services provided, reduces risks, and improves patient care. It also discusses five major strategies for improving clinical documentation:
- 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 article also points out the importance of being knowledgeable about ICD-10 official guidelines that address coding for uncertain diagnoses, with different rules for inpatient and outpatient coding. It recommends that physicians conduct a monthly or quarterly documentation self-audit of a select number of patient records to identify any issues and drive improvement.
OSI provides end-to-end medical billing and coding services for medical practices, dental practices, dentists and physicians and also specializes in insurance verifications and authorizations. The company provides practice management solutions for all medical specialties, from front office administrative management to back office coding, billing and collections. The company’s team of skilled AAPC-certified coders stays up-to-date with the current coding changes and updates, payer-specific documentation guidelines, and state and federal regulations.
A prominent industry magazine, BC Advantage Magazine is the largest independent resource provider in the industry for medical coders and billers, healthcare auditors, practice managers, compliance officers, and clinical documentation experts.
In addition to “Key Strategies for Improving Clinical Documentation in 2020”, the July/August issue of BC Advantage Magazine featured another OSI article: “Gastroparesis Awareness Month in August”
Other OSI articles featured in previous issues of BC Advantage Magazine include: “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 – : “Thanksgiving-Specific Foodborne Illnesses – Types, Symptoms, and ICD-10 Codes” and “ICD 10 Codes for some of the Worst Epidemics in the U.S” – were also featured in the magazine’s online medical coding article section.