Documentation "Pearls"
When determining "new" versus an "established" patient, only face to face encounters count for CPT's "3 Year" Definition.
Services
Medical record audits
- Documentation completeness and accuracy
- Clinical documentation improvement
- Satisfactory documentation for highest appropriate level coding: Coding, Charges, & Consistent Linkages
Clinical Documentation Improvement in preparation for future ICD changes
- The very near future holds coding sophistication as a certainty. Whether ICD-11 or beyond, the provision of high quality patient care as well as the payors will demand increased detail and specificity.
- Medical Record audits and feedback on coding readiness are necessary for optimal clinical care.
Provider education on CDI, ICD-10, and coding accuracy expertise
- Feedback to the Practitioner is crucial in gaining expertise in new coding protocols.
- This education can be in the form of feedback to the health care entity’s administration, directly to the Practitioner or a group setting as well.
- Assistance in learning to use coding software is also an effective means of learning as Practitioners take on more accountability for the coding process.
OB GYN Clinical Documentation, Coding and Billing Consulting
- Efficient charting and appropriate coding mean a safer and more productive OB GYN practice. Do you know the percentages of E/M Levels for your Practice? Do they compare well with Industry Standards? Are you being reimbursed for your "High Risk" Medicare patients annually vs. every two years?