tci Medicare Compliance & Reimbursement - 2017 Issue 2

Clip And Save: Never Underestimate the Importance of Detailed Documentation in Coding

Auditing your staff documentation techniques will keep your payments on the up-and-up. As the CERT results from 2016 highlight, practices can be their own worst enemies. Shorted out of millions, the report revealed that the primary culprit for most practice claims debacles were usually related to improper documentation. Whether it was a misunderstanding between physician and coder or a lack of sufficient information and necessity, Medicare providers in every state suffered major financial losses. Notes and codes. If the charting is messy and vague, then coders are left to decipher illegible documentationwith the tough job of translating these notes...

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