BC Advantage - 2017 Issue 1

Focus on Clinical Documentation to Improve Coding and Audit Results

Auditors spend their day surrounded by the end-product of the health care process - those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical record documentation. All too often however, auditors consider deficiencies and errors to be an error of coding when in fact, the errors arise from the clinical documentation. Just as a kitchen can only produce tasty, delicious meals when the ingredients available are fresh, wholesome and high-quality, healthcare providers can...

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