What We’re Reading – Boost Reimbursement through Improved Documentation: 5 Tips

Physicians and coders/billers need to be on the same page when it comes to getting claims processed and reimbursed correctly.  The key to this – and you’re probably sick of hearing it – is documentation.  Especially with ICD-10 coming around the corner, documentation is key and must be precise.  This article offers great tips on improving documentation; here are a few:

  • Do avoid EHR (Electronic Health Record) shortcuts –physicians’ time is valuable and with the use of EHRs, the ability to cut and paste and/or use a template for progress notes can be viewed as a timesaver.  Keep in mind, though, that a patient’s progress note is a vital document in correct reimbursement, especially if the payor asks for supporting documents.   If something is missing on unclear, due to poor charting, the payor might have a hard time determining the medical necessity for that service.
  • Do be exact when time is a factor – If a specific CPT (Current Procedural Terminology) code calls for a timeframe, the accurate time spent and what exactly was reviewed must be documented on the patient’s progress note.
  • Do give procedure specifics – If an injection is given in both knees – for example – be sure to have supporting documentation that the procedure was bilateral as well as the medication and dosage.  Or if patient has lesions, the measurements must be documented in addition to a notation of whether the margins were included or not.  Finally, any difficulties or complications that arose from a procedure need documentation about the physician’s determination.
  • Do provide full diagnosis detail – The coder can only code to the highest level of specificity with the documentation provided.  Be as precise as you can with a patient’s condition and/or complications – for example, if the condition is mild or severe, acute or chronic, diastolic or systolic, etc.  This will be a crucial element in ICD-10 coding because the use of the unspecified codes will slowly decrease.  Practice proper and specific documentation now so that when the coding change happens, the coder will be able to translate the documentation to the correct diagnosis code.
  • Do document E&M elements in full – For each patient visit make sure to meet or surpass the documentation guidelines for the three components in the E&M level: history, examination and medical decision-making process.  A frequent issue is under-documenting the Review of Systems (ROS) in the examination.

The common thread throughout this whole article is how vital proper documentation is and its importance in proper claims payment.

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