Providers and coders should work together to maximize reimbursement by ensuring accurate coding, which is validated by thorough medical documentation. By focusing on ways to improve medical documentation for better reimbursement, providers can enhance patient care and ensure accurate reimbursement. Here are five ways to improve documentation, patient care, and reimbursement:
1. Avoid EHR Shortcuts for Accurate Documentation
While EHRs streamline documentation, avoid using “cut and paste” features for patient information. Progress notes are essential for justifying continued hospitalization. Using shortcuts can make it difficult to demonstrate medical necessity. Ensure daily notes reflect the patient’s improvement or regression. Improve medical documentation for better reimbursement by providing clear documentation of the reasons for inpatient care to prevent reimbursement denials.
2. Provide Procedure-Specific Details in Surgical Notes
Surgical notes should clearly identify the approach, all procedures performed at the surgical encounter, and any unusual situations that happened during the operative session. For instance, multiple spinal injections necessitate that the provider identify whether the injections are bilateral in the same level or in several levels. Or, if a procedure is stated as “complicated,” the provider should be specific about how the determination was made.
For example, lesion measurements should be stated, and make sure to specify both when the measurement was taken and whether the measurement includes the margins. If the coder is left to rely on the pathology report for information on lesion size, the measurement will not be as accurate as it would be if taken and documented before the tissue was removed from the blood supply.
3. Ensure Comprehensive Diagnosis Reporting
Inpatient hospital claims are exclusively reimbursed based on the application of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. The Medicare Severity Diagnosis Related Group (MS-DRG) system categorizes medical conditions by their severity, encompassing co-existing complications and comorbidities that necessitate physician management or influence treatment. These conditions are further classified as either “standard” or “major,” with higher severity levels correlating to increased care requirements and, consequently, higher reimbursements.
If the medical record lacks clarity regarding the degree of impairment, coders may be unable to accurately capture the appropriate code level, potentially leading to reduced reimbursement. Congestive heart failure serves as a prime example of how vague physician documentation can negatively impact reimbursement. Undifferentiated congestive heart failure is not considered a complication or comorbidity for MS-DRG purposes.
However, specifying the condition as “chronic systolic” or “diastolic” congestive heart failure qualifies it as a standard complication or comorbidity, thereby increasing reimbursement. Further detailing the condition as “acute-on-chronic systolic” or “diastolic” congestive heart failure elevates it to a major complication or comorbidity, resulting in even higher hospital reimbursement.
Improve medical documentation for better reimbursement by ensuring meticulous and precise documentation. This is essential not only for maximizing reimbursement but also for ensuring accurate medical recordkeeping. Inpatient coders are responsible for reporting all applicable codes that accurately reflect the patient’s conditions. The medical accuracy of the patient record is paramount for successful care delivery. Moreover, hospitals utilize these codes to gather and report statistical data on treated patients.
4. Accurate E&M Code Reporting: Documenting the Three Key Components
To accurately report E&M codes, it’s essential to fully document all three key components: history, examination, and medical decision-making. For visits like new patient evaluations, emergencies, consultations, initial inpatient encounters, and observation services, the documentation must meet or exceed the required level for the chosen code. In particular, the review of systems (ROS) section should be comprehensive enough to justify the reported code level.
5. Accurate Billing for Time-Sensitive Services
When billing for services like new patient visits, emergencies, consultations, initial hospital stays, and observation, it’s crucial to ensure that the level of care provided aligns with the billing code. This means thoroughly documenting patient history, physical examination, and complex medical decision-making. A common oversight is insufficient detail in the review of systems, which can weaken the justification for higher billing codes.
Optimize Reimbursement with Allzone: Essential Documentation Tips
Accurate documentation is essential for maximizing reimbursement in medical coding companies, particularly when using Allzone MS. By focusing on ways to improve medical documentation for better reimbursement and ensuring that all patient information is captured comprehensively, coders can accurately represent the complexity and necessity of treatments, leading to fewer claim denials and higher revenue.
One key area for improvement is the use of Electronic Health Records (EHRs). While EHRs streamline the recording process, they can also lead to shortcuts that compromise accuracy. Providers should focus on documenting daily progress notes to clearly justify continued hospitalization. Surgical notes should also be detailed and specific. Information like injection sites and lesion measurements can significantly impact coding accuracy and reimbursement.
Complete diagnosis documentation is crucial. For example, specifying ‘chronic systolic’ heart failure rather than simply ‘congestive heart failure’ can lead to more accurate reimbursement. By fostering collaboration between providers and coders and prioritizing efforts to improve medical documentation for better reimbursement, medical coding companies using Allzone MS can enhance claim processing, reduce denials, and improve overall financial outcomes for healthcare providers.