The core of any patient encounter at a clinical institution is medical record documentation, as it validates the level of patient care provided. Legitimate clinical documentation has always been vital in the healthcare industry and is deemed even more significant with current changing trends in billing and coding.
The insurance companies pay physicians for the services rendered based on the codes assigned to their provided level of service. Relevant codes for diagnosis and procedures can only be billed if concise and complete documentation is produced, explaining why the respective procedures were performed on the patient.
So, documentation is critical for claims to be coded accurately, expediting reimbursement. Keep reading to learn more about how documentation and coding go hand in hand.
Why Is Documentation Critical?
The accuracy of documentation and coding directly impacts the revenue management process. Incomplete or inaccurate documentation of a patient encounter can hinder the claims processing, causing the insurance companies to reject the claims. This leads to healthcare providers investing extra time in editing and resubmitting claims.
Inaccurate coding can result in a practice receiving less reimbursement than it deserves for the level of service provided. Coding errors can also lead to legal repercussions, such as a lawsuit for billing fraud.
Moreover, with coding errors instigated by missing or incomplete documentation, appealing denied claims and insurance reviews can become quite challenging. Using EHR (electronic health records) systems can help minimize documentation and issues, preventing reimbursement delays.
This way, accurate coding will provide healthcare practices with data that helps them make informed decisions when it comes to revenue and patient care. Not just that, coding data which is drawn from documenting a patient encounter is also crucial for research initiatives.
Medical coding is performed to document the procedures and services rendered during a patient’s visit, which becomes a permanent part of the patient’s medical history, whether it includes x-rays, lab test results, or prescriptions. So, to protect patients in the scenario where procedures documented and coded by your healthcare organization are revisited for future medical care, it’s essential to accurately document the services provided.
Key Documentation Practices In Medical Coding
Here are some documentation practices that can help healthcare organizations perform accurate coding.
When healthcare organizations use a consistent format for documenting all patient encounters, it ensures all key elements, including examination findings, history of illness, and treatment plans, are consistently captured in the format. This helps maintain patient care continuity.
Keeping documentation consistent by using standardized medical terminology, using uniform abbreviations, accurate timestamps of the encounters, and documenting any changes in patients’ condition during their visit facilitates medical billing service in maintaining coding accuracy.
Delayed documentation is one of the major causes of omissions and errors in patient care and medical coding, especially, if several physicians are performing subsequent care on a patient.
Ensuring that a patient encounter is recorded promptly leads to updated and accurate information. This helps organizations prevent any errors stemming from missing or incomplete information.
Healthcare organizations should educate their staff regularly on following best documentation practices so they can keep pace with the updated coding guidelines and compliance requirements, ensuring accuracy in monitoring a patient’s visit and assigning relevant codes.
If there is ambiguity present in the recorded documentation, it can cause coding errors, which further serve as reasons for denied reimbursements. Not just that, using unclear notations when recording a patient’s medical condition can become a potential threat to the patient’s safety. Use of such notations and illegible handwriting should be avoided to streamline the reimbursement process.
Medicine is becoming increasingly complex due to innovation which implies a simultaneous increase in the complexity of medical documentation. To reflect such complexities, the ICD-10-CM coding set was proposed, which can be one of the most challenging coding sets yet. One main reason for that is the astronomical set of guidelines medical billers and coders must review when assigning a code.
ICD-10 allows more specified coding which is why physicians are now required to be more specific when documenting procedures and conditions. Specificity in documentation will allow coders to assign the appropriate CPT codes to services and procedures, reducing the room for error in coding.
Relevance and Privacy:
Healthcare providers should avoid adding extraneous information when documenting a patient’s condition as it can complicate the coding and billing processes. Instead, only information relevant to the treatment provided to the patient, the patient’s medical condition, and billing should be included. For legal reasons, providers must adhere to privacy standards and regulations when documenting patient information.
- What are the three main benefits of accurate documentation and coding?
The three main benefits of accurate documentation and coding include providing an appropriate level of patient care, preventing denied claims and acquiring timely reimbursement, and accumulating data for revenue management.
- How does documentation improve patient care?
Accurate documentation minimizes the risk of errors in patient care and improves communication among physicians regarding a patient’s medical condition and performed procedures.
- Who is responsible for proper documentation and correct coding?
While a physician is ultimately responsible for correct coding and proper documentation, a joint effort between the physician and medical coders facilitates precise reporting of procedures and diagnoses.
- How does inadequate documentation impact coding compliance?
Inadequate documentation can lead to coding compliance issues, including missing complications, incorrect presence on admission, incorrect principal diagnosis selection, and incorrect memorization of procedure or diagnosis codes.