Is Your Documentation in Good Standing? 10 Keys to Proper Documentation!
Ignorance is not bliss when it comes to your documentation.
Providers should always stay abreast of new changes that can affect their practices.
It's hard for providers to stay current with new changes for ICD-9 (soon to be ICD-10) but it's not impossible.
A provider should understand that while taking care of a patient is of the highest priority, documentation for services provided is inclusive to the patients overall care.
Level of specificity is one of many reasons that delay or deny payments.
ICD-10 is going to play a significant role in the Level of Specificity and laterality (Left vs Right).
Documentation will require more specificity in terms of site (location), Trimester vs weeks (OBGYN), etiologies of conditions, when, where and how an injury/event occurred.
Also, the status of a patient (Civilian vs Military).
With that said, How should a physician keep his/her documentation in good standing? Below are 10 keys to proper documentation that can help you stay on track! 1) Have an experienced biller/coder that understands the ICD-9 guidelines and how it relates to your practice.
2) Communication is another important (dare I say the most important) tool for the provider to have.
3) A provider should schedule regular meetings with their billing,coding or office manager to discuss areas of concern.
4) Allow an internal audit, if you need this to be outsourced, do so.
Don't be afraid of the results, use the results as a stepping stone to get better.
5) Educate your ancillary staff (nurses, techs, etc..
).
6) Consult outside help if needed (this can save a lot in the long run).
7) Only use updated resources (ICD-9 & CPT4 books) 8) Check with your medical societies, they always have useful information! 9) Always document and code diagnoses/ procedures to the highest level of specificity.
10) and lastly, DON'T SHOOT THE MESSENGER, accept that changes are always bound to happen.
A certain diagnosis code may have a certain descriptor one year, then the next year the descriptor may have been deleted, revised or another diagnosis may need to be added.
Coding professionals are always keeping up with the latest information.
Thus, discussing the updated and edited changes passed down from the cooperating parties.
In this day in age, documentation can make you or break you.
Many providers have been prone to law suits due to documentation infractions! A physicians documentation is used for determining payment, quality of care, disease trending and to some degree, certain benefit coverage & more.
Providers should always stay abreast of new changes that can affect their practices.
It's hard for providers to stay current with new changes for ICD-9 (soon to be ICD-10) but it's not impossible.
A provider should understand that while taking care of a patient is of the highest priority, documentation for services provided is inclusive to the patients overall care.
Level of specificity is one of many reasons that delay or deny payments.
ICD-10 is going to play a significant role in the Level of Specificity and laterality (Left vs Right).
Documentation will require more specificity in terms of site (location), Trimester vs weeks (OBGYN), etiologies of conditions, when, where and how an injury/event occurred.
Also, the status of a patient (Civilian vs Military).
With that said, How should a physician keep his/her documentation in good standing? Below are 10 keys to proper documentation that can help you stay on track! 1) Have an experienced biller/coder that understands the ICD-9 guidelines and how it relates to your practice.
2) Communication is another important (dare I say the most important) tool for the provider to have.
3) A provider should schedule regular meetings with their billing,coding or office manager to discuss areas of concern.
4) Allow an internal audit, if you need this to be outsourced, do so.
Don't be afraid of the results, use the results as a stepping stone to get better.
5) Educate your ancillary staff (nurses, techs, etc..
).
6) Consult outside help if needed (this can save a lot in the long run).
7) Only use updated resources (ICD-9 & CPT4 books) 8) Check with your medical societies, they always have useful information! 9) Always document and code diagnoses/ procedures to the highest level of specificity.
10) and lastly, DON'T SHOOT THE MESSENGER, accept that changes are always bound to happen.
A certain diagnosis code may have a certain descriptor one year, then the next year the descriptor may have been deleted, revised or another diagnosis may need to be added.
Coding professionals are always keeping up with the latest information.
Thus, discussing the updated and edited changes passed down from the cooperating parties.
In this day in age, documentation can make you or break you.
Many providers have been prone to law suits due to documentation infractions! A physicians documentation is used for determining payment, quality of care, disease trending and to some degree, certain benefit coverage & more.
