If you’ve heard this once, you’ve heard it a thousand times: if it isn’t documented, it didn’t happen. Nor can you bill for what was not documented. One continuing issue for most healthcare providers is adequate documentation of services. The big move to an ICD-10 coding standard, along with various regulations and industry changes, will create another level of complexity. From the physician to the coder to the medical biller to the patient, documenting services accurately and with supporting detail will impact coding, billing, and reimbursement. Here are a few guidelines to safeguard timely reimbursement in the months to come.
Medical billers and coders must have the most specific high-level description in the ICD-10 standard for the patient’s visit. Confirm your documentation includes laterality, severity, and complexity of conditions as well as condition/visit type and external causes. Screen out qualifiers such as ‘probable, questionable’ or ‘rule out’ and minimize usage of ‘non-specific’ codes.
Specific regulations stop coders from linking a condition to a causal factor without proof. That means physicians have to be vigilant about documenting a clear, organized and detailed timeline, ensuring diagnoses and procedures codes have critical supporting data for medical necessity.
Some doctors create their own shorthand or terminology for chart notes. This can be incredibly confusing, and might sacrifice some level of compliance. Use commonly accepted abbreviations and terminology so your documentation is clear to anyone reviewing the chart.
Some payer rules clearly state that documentation has to have the right provider’s signature. Here, an electronic signature may be more useful, but it's critical that the doctor sign-on is present and that it’s the right doctor, the attending physician or other responsible professional, who is attaching their credentials to documents.
Physicians, as well as other key staff members, should understand the rules and documentation required when it comes to assigning ICD-10 codes, and other areas of medical coding in general. There are hundreds of training options to fit every budget. Physician speciality trade groups are a great resource, to inform and educate your office on not only the rules, but how to assign them accurately for sustained reimbursement.
Regulators are clear about stating that conditions need to be cited as often as they are addressed in treatment. It's important to specify either history or current conditions, but it's also important to keep tagging the conditions as they're being treated, because this shows a clear link to conditions that are being tracked, patient quality of care, and the documentation trails that may be necessary for a denied claim or chart audit.
In some cases, using a “history of” tagging will mistakenly show that a patient no longer has the current condition or the tagged documentation is not relevant to the current visit. Be cautious on using shortcuts and study the use of time qualifiers in coding for accurate assignment and reporting of patient data.
Complete and legible documentation is a must - for your sake and others who rely upon the accuracy of your notes for coding and reimbursement. The Centers for Medicare and Medicaid Services maintain that auditing personnel “will not guess” at what is supposed to be on a document. Digital record and easy to use voice to transcription systems are helping with this, however, there continues to be a need that the information you relate is decipherable by other stakeholders.
The details count - now more than ever - because it seems payer rules change on a daily basis. You may have received a denial because the payer required the reason for the patient’s disability. This is to provide a qualified timeline for conditions in order to establish medical necessity and eligibility for treatment.
Essential resources may be a combination of electronic and paper -- make sure they are kept up to date. Some very good ones are at no to low cost while others require a hefty fee. Do your due diligence in connecting with materials that fit your budget and speciality; perhaps you can do a bulk rate purchase with others in your area. Having the right data at hand when you require it will be highly critical to your billers, coders and other staffers. Invest in these materials to improve documentation of your services, and you’ll see a return in better reimbursement, less claim delays, and denials.
Think about how much time you can save, not to mention your bottom line results, by thoroughly documenting your services the first time. Your patients and your office team will be grateful.
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