Why Quality Documentation Matters

Posted by Nancy Clements on Nov 10, 2021 3:45:00 PM
If you work with provider claims in a medical office, then you have probably heard the phrase, “If it isn’t documented, it wasn’t done.” But a 2020 Center for Medicare and Medicaid Services (CMS) report found that more than 70 percent of claims submitted for payment were paid improperly, meaning something was incomplete or missing from the documentation submitted with a claim.

The Medicare Fee-for-Service Supplemental Improper Payment Data report found that 74 percent of the Part B improper payments were due to missing/inadequate documentation. The missing information included things like inadequate documentation to support medical necessity or missing orders. Other problems stemmed from inadequate documentation to support the services provided or other documentation required for payment of the code.

If your office receives frequent claim denials, it could trigger an audit. The False Claims Act may hold liable any person who submits a claim to the federal government that he or she knows (or should know) is false. Knowing what to look for when reviewing documentation is a proactive way to prevent improper payments and keep the practice out of legal trouble.

PMI Instructor Jan Hailey, MHL, CMC, CMIS, CMOM, CMCO, says the importance of quality documentation in the medical record cannot be overstated. It protects patient safety and coordination of care between providers and across the healthcare continuum.

Jan has extensive experience teaching coding and reimbursement staff across the country how to achieve complete and accurate reimbursement with proper documentation and claims management.  She developed a documentation improvement program for Saint Joseph Physician Network in Mishawaka, Indiana in 2015, where she served as Director of Care Management with Select Health Network. While working with Saint Joseph, she implemented a program for Hierarchical Condition Category (HCC) coding to improve risk scores and worked closely with providers, management, staff, community, and payers to develop strategies for process improvement, gap closures, and patient experience. 

Learn Jan's best practices in her 1-hour continuing education topic: Why Quality Documentation Matters, Go through the root causes of inadequate documentation and get expert guidance that will help your practice achieve complete and accurate reimbursement. 

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Topics: carrier contract guidelines, medical billing, Medicare fraud, medicare compliance, patient billing

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