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How Can Accurate Documentation Enhance Practice Revenue?

July 24, 2013

In the last five to ten years reimbursement for medical practices has been impacted by various changes in the healthcare industry. These changes include HIPPA tightening their requirements for data submission, upcoming ICD-10 final implementation date coming closer, amongst various others- which have a direct impact on medical documentation and hence on the medical practice’s cash flow generation.

Even as the healthcare landscape is changing and physicians strive to adapt to these changes, the American Medical Association (AMA) reported a 2% increase in billing errors over the last year. Additionally as denials due to erroneous documentation have been increasing, an estimated cost of $1.5 billion involved in correcting and re-filling these claims has been reported.

Hence adequate and correct medical documentation is very essential for health care services - right from providing qualitative medical care to receiving timely payment benefits from the insurance provider. This also helps in eventually minimizing the cost involved during refilling of claims. There is a very popular saying “If it is not documented, it did not happen”, and this can be most aptly applied to medical billing; where it means that if any treatment provided is not documented, then the healthcare facility will not be paid by the insurance provider.  

Very often in hospitals one patient is treated by different doctors, if the documentation is not appropriate the treating doctor will not be updated on the treatment provided and hence negatively affecting quality of patient care. There are even cases reported wherein doctors are charged for negligence due to incorrect or incomplete documentation. Documentation also serves as legal protection for both physician and patient saving from legal charges.

Without a proper documentation system a physician cannot function at an optimum level. A small error on the documentation part will lead to denial and then re-filling, which will directly impact the revenue.

Few important details to be assessed to avoid documentation errors

  • The insurance details of the patient related to its eligibility and coverage need to be checked properly. If not checked efficiently at first instance can prove to be fatal later
  • Medical treatment is a complicated process and very often it is difficult to define it with prevailing ICD codes, at such a time it is necessary to use modifiers efficiently so that treatment and incidental services provided are clearly understood. Inappropriate use of modifiers will render descriptions as unclear
  • Coding in form is mainly prone to errors. Physicians are expected to enter codes for both treatment as well as incidental services provided. If either of it is not entered correctly the reimbursement would be denied or partly paid
  • Failure to put signature is an addition to the list of errors. It is important for physician to validate the submission of claim
  • Abbreviations used in documents to describe the treatment need to be appropriate
  • Physicians need to be careful in maintaining the secrecy of patient history or else it would attract legal penalties. In such a scenario very often even State and Federal law supersede HIPPA

Consequently due to the various issues related to documentation, Electronic Health Record (EHR) has gained predominance. According to a recent survey EHR provides accuracy with decreased cost-82% of providers report that sending prescriptions electronically (e-prescribing) saves time, while 70% report that it enhances data confidentiality.

Proper documentation can prove to be an important key for physicians to help reduce denials and boost practice income. In such a scenario it is always advisable to outsource the process of medical documentation. Companies like MedicalBillersandCoders.com (MBC) after investigate into the clinics medical process to find loopholes and suggest appropriate measures to help improve documentation.

MBC is the largest consortium of billers and coders across 50 US States has been providing both RCM and consultancy services to healthcare providers for over a decade now. Our experts’ billers and coders are completely committed towards providing accurate documentation, adopting various quality measures and constantly updating themselves with healthcare industry changes. MBC can also assist your clinic in updating software related to EHR and save physicians from various documentation errors and hurdles.


Category : Revenue Cycle Management