Your weekly dose of wisdom from the Physicians Practice experts.
With all the useful information available on Physicians Practice, it is easy to become overwhelmed.
With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In the July 2021 article on boosting reimbursement through improved documentation, Dorothy Steed, RN writes the following:
Providers and coders need a cooperative relationship, working toward a common goal of complete coding and positive reimbursement results, as supported by medical documentation.
Here are five tips to ensure better documentation and, along with it, better patient care and improved reimbursement:
1). Avoid EHR shortcuts - Documentation shortcuts can create difficulty in supporting medical necessity for the patient’s continued inpatient status.
2). Give procedure specifics - Surgical notes should clearly identify the approach, all procedures performed at the surgical encounter, and any unusual situations that happened during the operative session.
3). Provide full diagnosis detail - If the record is unclear regarding the degree of impairment, the coder may not be able to capture the code level that will yield a higher reimbursement.