tci Part B Insider - 2013 Issue 45

Part B Compliance Coach: Focus on 5 Areas for Improvement in Your Provider Documentation

While EMRs improve legibility, they may lead to other issues. When your practice faces an audit, the payer is not only going to look at your coding accuracy, but also your documentation compliance. If you fall short, you could be setting your practice up for paybacks, fines, or worse. Ensure your providers’ documentation will stand up to payer and government scrutiny by focusing on these five key areas for improvement. 1. Start with Authentication Requirements Every medical record must have authentication. Every service your medical staff provides or orders should be authenticated by the author, says Marsha S. Diamond...

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