In the real world, dealing with medical documentation is a complete nightmarish and OB/GYN documentation is no different. Why? Inaccurate, incomplete documentation process is leading to several hiccups in insurance claims reimbursements OB/GYN.
Discharge summaries and other important information are often not available at the time of coding. Such misleading and incomplete information results into incorrect missed-out coding which in-turn can cause loss in revenue, productivity and profitability creating compliance issues. According to federal and state regulations, patients’ histories and diagnostic and treatment documentation supposed to have completed and submitted within 24 hours, while overall record has to be completed within 30 days, and often DS fall within this time period.
OB/GYN healthcare professionals very well knows the effects of unfinished, delayed or wrong clinical documentation overall affecting the financial bottom line, performance-improvement activities such as review of serious cases, and compliance with federal and state governing laws. Thorough and precise documentation is the basis of all medical coding, billing, and claims submission and follow-ups. With the correct medical and billing coding of OB/GYN services it makes it easy and hassle free in receiving accurate payment which in turn, hinges around quality, precise, and thorough clinical documentation.
It is important that your OB/GYN documentation should be legitimate and complete. How do you know that your documentation work is in line?
A Correct Medical Billing And Coding Will Offers Services Like:
- Selection of the correct diagnostic, treatment, and re-habitation codes-that describe more accurately “what” and “why” “who” and “where” of the OB/GYN process
- Consistent with coding guidelines
- Coding to the highest degree of specificity
- Linking the ICD-9/10 to the correct CPT-4 on the claim form
- Linkage and Medical Necessity: ICD-9/ICD-10 codes “justify” the services provided
- Failure to appropriately link leads to denials and delays of reimbursement claims
- Avoiding bundled codes
- Coding only relevant OB/GYN diagnoses
- Sequencing the OB/GYN diagnoses
- Correctly understanding the billing requirements of each insurance agency, which varies from agency to agency, as well as with federal and state-specific regulations
To Flourish Your Practice, Below Are Few Critical Things To Watch Out For:
Ensure that your documentation process is in sync with the latest emerging documentation trends, guidelines, and formalities related to OB/GYN. This will boost your coding accuracy, decrease insurance reimbursement claims denials, and safeguard your payments.
- Be acquainted with ICD-10 related Ob-GYN documentation that is needed as diagnosis system changes. Stay up to date on the most timely, relevant, and accurate ob-gyn coding guidance straight.
- Find your way out of coding tight spots thanks to precise and thorough supporting documentation.
- Implement the latest coding, compliance, legal and regulatory updates.
- Documentation and coding principles are intimately linked and affect patient care, reimbursement, and compliance. An understanding of the principles is required for the successful practice of modern-day OB/GYN practice.
The Documentation Of Each Patient Should Include:
- Reason for the supposed medical diagnosis, and relevant history, physical examination findings and prior diagnostic test findings, as well as the patient’s progress, response to and changes in treatment, and revision of diagnosis according to the level of service provided.
- Assessment, clinical impressions or diagnosis, and identification of risk factors.
- Plan for care and the actual time spent plus date and identity of the clinician.
- Ensure that the CPT and ICD9/10-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
How to Boost-Up Your Revenue and Profitability of Your OB/GYN Practice?
It would be a wise and judicious decision for OB/GYN medical practitioners to outsource their documentation and coding worries to a professional medical billing and coding service provider. Having an established name on board for your medical billing and coding will ease out your revenue cycle and other operations. The service providers are specialized in OB/GYN documentation, coding, and billing hence they are familiar with the procedures, treatment and terminologies concerned in OB/GYN services in the USA.