Here are four tips for hospital billers and coders to more accurately capture and document patient encounters, according to The Hospitalist.
1. Thoroughly capture the first visit. Hospital documentation consists of history, physical examination and medical decision-making. The history also includes the chief complaint. Though the history is commonly disregarded in documentation but this could result in down coding.
2. Include the actual diagnosis. Coders will often see indicators of a diagnosis but not code it unless the physician writes it down. If the physician leaves out the diagnosis, check with them to submit a complete claim.
3. Note the severity of the case. By indicating the level of a patient's case severity, you are documenting the reasons for certain tests to be performed. The documentation should elaborate how a patient responds to a certain treatment and whether the condition becomes better, stable or worse.
4. Sign, date and time your progress note. A signature may seem like a small detail, but it's important. Medicare and commercial payors can opt not to pay if a signature is illegible.
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1. Thoroughly capture the first visit. Hospital documentation consists of history, physical examination and medical decision-making. The history also includes the chief complaint. Though the history is commonly disregarded in documentation but this could result in down coding.
2. Include the actual diagnosis. Coders will often see indicators of a diagnosis but not code it unless the physician writes it down. If the physician leaves out the diagnosis, check with them to submit a complete claim.
3. Note the severity of the case. By indicating the level of a patient's case severity, you are documenting the reasons for certain tests to be performed. The documentation should elaborate how a patient responds to a certain treatment and whether the condition becomes better, stable or worse.
4. Sign, date and time your progress note. A signature may seem like a small detail, but it's important. Medicare and commercial payors can opt not to pay if a signature is illegible.
More Articles on Coding, Billing and Collections:
Humana Inks In-Network Contract With Halifax Health Twin Lakes Surgical Center
MedPAC Proposes 0% ASC Payment Increase in 2014
ASC Industry Leader to Know: John Bartos of Collect Rx