Clinical Documentation: Great Way to Improve Coding

Medical documentation and coding are bricks and mortar of the medical billing process. In the past 25-30 years, we seen the increased importance of documentation and coding. Compliant clinical documentation and coding are essential to every healthcare setting, no matter the individual responsible for and/or performing the tasks.

We need to ensure medical necessity is being met, of course, but not to a fault, whereby we are utilizing diagnoses only to obtain the coverage and medical necessity acceptation. We shouldn’t be making or using the EHR (electronic health record) or other technology to lead physicians to a particular diagnosis on the screen or use technology to game the reimbursement system(s).

Documentation as Foundation for Accurate Coding

A core designated clinical documentation set for coding should be used as the key constant source of clinical documentation by coding professionals as they conduct all the medical coding for an organization. The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement, and policy-making.

Complete, clear, and accurate health record documentation is the foundation for complete and accurate coding. This documentation (electronic or paper-based) must be clear, accurate, complete, and timely in order to produce quality coded data.

Policies should include facility-specific documentation requirements, payer regulations and policies, and contractual arrangements for coding consultants and outsourcing services. The outsourcing vendor does not tell you what documents they will use to code your encounters; you, the HIM professional, are in charge of this process and should have your outsourcing partner follow your best practice or coding compliance policy.

Transition to ICD-10

Due to the transition from ICD-9 to ICD-10, some documentation subjects will require providers to capture new information while for others it may involve in updating, modifying, and expanding documentation needs. ICD-10 contains multiple combination codes and documentation must reflect the association between conditions, let’s understand this with the following examples:

  • In ICD-10 the diagnosis code K50.814 indicates ‘Crohn’s disease of both small and large intestine with abscess.’ While in ICD-9, equivalent code would be ‘555.2, regional enteritis, small intestine with large intestine’ and ‘569.5, Abscess of the intestine.’ In addition, laterality necessitates documentation.
  • Let’s consider another example, in the ICD-10 diagnosis code, M05.271 indicates ‘Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot. While in ICD-9 equivalent code would be ‘714.27, Rheumatoid arthritis with visceral or systemic involvement, ankle, and foot.’

Importance of Accurate Billing Documentation

Accurate medical billing documentation is a must for many reasons. For one, it exists as a legal document which will prove the services rendered, as well as why those services were rendered and/or why the patient was seen by the provider. The documentation may also serve as evidence in a court of law.

An excellent notation will also serve as effective communication of your plan of care and thinking to other providers in a professional manner. For medical billing purposes, it will provide solid documentation of the service(s) rendered, which can then be confidently and compliantly billed.

Clinical documentation and coding need to ensure that it is a true reflection of the patient care that was provided-not simply the correct words or codes that ‘pay.’ Thorough, detailed documentation leads to accurate coding, and accurate coding leads to appropriate and timely claims payments for hospitals and physicians.

Most importantly, accurate documentation can lead to better, more effective patient care. It can provide more detailed information to other health care providers performing subsequent care or services on patients.