Proper Documentation Practices can Optimize Medical Coding Services

Proper Documentation Practices can Optimize Medical Coding Services Physicians can help medical coding companies optimize the services they provide by ensuring proper documentation of diagnosis and treatment.

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Submitting claims with accurate procedural (CPT), diagnostic (ICD-10), and HCPCS Level II codes is necessary for proper reimbursement. Changing requirements and industry regulations have made medical coding a challenging task even for service providers.

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helping medical coding companies optimize the services they provide with proper documentation practices, physicians can enhance their practice revenue.

Documentation Tips to help Physicians Maximize Revenue 

Ensure legibility in documentation: Evaluation and management (E/M) services make up a significant share of most physicians’ billable services. CMS requires that all entries in the medical record are legible. Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and lead to medical errors or other adverse patient events. Legible documentation will promote accurate coding for maximum revenue.

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Document time for prolonged services: Additional care may be provided to a beneficiary after an EM service. When claims are submitted for prolonged services they should be supported by documentation of time. In fact, audits for prolonged services often show that such documentation is missing. Prolonged service code(s) may be added to a base EM code only for the services of the rendering provider.

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Record history of present illness: History, exam, and medical decision-making (MDM) are the three main components of an E/M service. History consists of the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). Experts recommend that physician should record the CC, HPI, and MDM and leave the recording of the ROS and PFSH to the ancillary staff. This will help the medical coding and billing company identify all components correctly and avoid coding errors.

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Document diagnosis to the highest level of specificity: This is the crux of ICD10-CM coding. Accurate documentation indicating laterality and other finer details allows coders to code to a much higher level of specificity under ICD-10. For instance, in the case of “closed fracture of distal phalanx of hand,” details should be provided about the type of fracture, on which finger, on which hand, and even which visit it is for this particular injury.

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Carefully document counseling, risk factor reduction and behavior change intervention: These services involve time-based codes, which require careful

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documentation of time spent and a summary of the discussion. The team in a reliable medical coding company will take care to submit these claims in keeping with the reimbursement policies and coverage guidelines of insurance providers.

Choose the Right Medical Coding and Billing Company Regardless of how careful they are with their documentation, physicians can maximize their revenue only by choosing the right service provider with extensive experience in providing reliable medical coding services. Such companies have skilled coders who are well-versed in CPT and ICD-10 codes and work with advanced resources to provide comprehensive services covering every aspect of their client’s revenue cycle. With the right service provider, physicians can expect accurate, timely, cost-effective coding and billing solutions.

www.outsourcestrategies.com

Phone: 1-800-670-2809