There is no escaping the fact that coding drives revenue. Correct coding means you are appropriately paid for the work you do. For many practices, one of the most difficult challenges is persuading providers to thoroughly document encounters to ensure correct coding. Despite the strides in EHR technology and the continuous pressure to provide information for quality measures, some practices are continually leaving money on the table because their medical documentation does not contain enough information to completely and accurately code. Below are our top tips to ensure you are being compensated correctly for the services you provide:
Even if there was no financial incentive to document thoroughly, ensuring continuity of care for the patient should be a top priority. Patient history and examination notes are highly contingent on the reason for the visit – and past treatments are usually reviewed during the encounter. However, coding can involve previous treatment attempts. Therefore, they need to be acknowledged in the record for the current encounter. For example, a patient presents with back pain. Not only is it useful to know what past treatments have been tried and ineffective; in some cases, it is necessary to identify those previous treatments (such as taking ibuprofen) to assign the correct code. Pulling still-active diagnosis into the encounter, as well as making notes of pertinent history, confirms they have been acknowledged and considered in the treatment plan
Comorbidities are an essential part of the patient record, not only for diagnosis and treatment plans, but also for claims. Medical necessity evidence often requires a complete picture of the patient. For example, a history of smoking may be necessary for some insurance companies to cover specific tests or scans. Without the history of tobacco, the charge may be denied. The expectation that a coder will look back in the patient record for any type of coding information leaves room for error and is not best practice.
The only record coders can use is the provided medical documentation. In instances when a particular procedure is always done with another, both procedures should be recorded. A provider should never assume that a coder knows something has been done because it always is.
CMS and insurance companies frequently update codes, and the information necessary for a new code is always available. Scheduling at least two new code updates per year with providers can have a significant positive impact on revenue and the claims cycle as a whole. It also provides a forum where questions can be asked to clarify what documentation is required for problematic codes.
Some EHRs can use templates to help guide documentation during the visit to ensure accurate coding. Not everyone is a great typist. Therefore, voice recognition technology or scribes can be utilized to help record the entire encounter into the patient notes. If templates are not available in your EHR, written prompts and reminders to record a complete patient record can be helpful. Without open avenues of communication about coding, the entire claims process can be frustrating for everyone – and have a severe negative impact on revenue.
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