How To Avoid Careless Coding: Proper Documentation

“Careless coding jeopardizes reimbursement, and can also lead to fraud and abuse issues. One of the most common mistakes results from poor OP report documentation. And, another involves miscoding procedures due to misunderstanding of the correct coding initiatives edits.”

“Avoid The Four Most Common & Costly Coding Mistakes” Ambulatory Surgery Compliance & Reimbursement Insider. May 2007

Careless coding is not always the direct result of the coders’ mistakes, but rather an error in the physician’s documentation. Basically, physicians and coders speak two different languages – coders speak code-book language and physicians speak clinical language. One would assume that code-book language would rightly align with clinical language; however, that is not the case in the healthcare industry. With such a vast language barrier, how can we expect coders to make accurate decisions of assigning codes when the physician documentation does not match the code-book language they’re required to speak for accurate, compliant documents sent to their third-party payers?

Point-of-Service Documentation: Do you know the value?

“IPA’s should use point-of-service methods to increase quality and ensure the collection of quality data, by central distribution of prompts containing quality codes. Prompts and reminders are important tools to assist physicians in addressing care that may be overlooked or missed.”

“Medicare Quality Codes & Their Impact on Physicians” ICLOPS, LLC. December 2005

Independent Practice Associations (IPA’s), along with other types of healthcare organizations should use point-of-service methods to capture quality data. Capturing quality codes is vastly important. How will physicians know what and how to capture if they don’t have the knowledge and the tools to do so? ComplyMD’s point-of-service documentation solution allows physicians to properly document their procedures and diagnoses, in a code-ready format.

The software doesn’t necessarily ‘prompt’ physicians; however, it provides them with an ‘other procedures/diagnoses to consider’ suggestion box.

Pay-for-Performance: Will you be a loser?

“Pay-for-performance reimbursement plans and consumer-directed health plans both depend on assessing and distributing information on clinical performance. Physicians who don’t have the means to track their own clinical results will be losers, literally, of patient volume and revenues.”

“Medicare Quality Codes & Their Impact on Physicians” ICLOPS, LLC. December 2005

With these new plans and governmental mandates, physicians need to be equipped with the tools to properly, easily and efficiently track their own clinical results. Capturing appropriate documentation of diagnoses and procedures will result in capturing appropriate revenue for the facility and the physician. ComplyMD is a web-based application located inside or immediately outside the OR to help physicians capture appropriate documentation, at the point of service. The more time physicians wait to document (dictate) their procedures, the more room they leave for error in their documentation.

ComplyMD gives physicians multiple choice lists of proper, code-ready documentation of diagnoses and procedures. It creates a comprehensive operative note for the patient encounter that’s ready to be sent to the coder’s office, immediately after the procedure. ComplyMD gives physicians the tools to track their own results so they will not be losers of patient volume and revenues, and their facilities will not be found as losers either.