Most physicians understand the importance of documenting services effectively and yet still miss crucial elements while documenting services. To ensure proper reimbursement, physicians, coders, office managers and auditors must understand the major physician documentation issues that affect reimbursement.
Some of the problem areas physicians can encounter in the quest to improve their clinical documentation include auditing documentation and common documentation errors identified by the Recovery Audit Contractors (RAC) and Comprehensive Error Rate Testing (CERT) programs. Evaluation and management (E&M) services commonly identified by CERT, as well as E&M medical necessity and Medicare’s policy on medical necessity are other areas of concern.
Physicians Increasingly Subject to Pre- and Post-Payment Audits
Physicians are increasingly subjected to pre- and post-payment audits, as well as third-party scrutiny. Payment is affected by lack of specificity in clinical documentation, but connecting it with quality of care and physician reimbursement is a challenge. Even when physicians have been getting paid for their services, continuing payment is not a certainty unless their documentation supports the services they provided. To ensure proper reimbursement, improving clinical documentation is essential.
Analyze and Correct Common Documentation Errors Identified in Audits
In the upcoming webinar “2017 CMS Guidelines for Physician Documentation” with industry veteran Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, on Tuesday, June 27, 2017, Melanie will cover the general principles and legal aspects of physician documentation. The session will cover the documentation guidelines provided by the Centers for Medicare & Medicaid Services (CMS) as well the OIG recommendations.
Melody will analyze medical record documentation to identify the biggest issues that affect physician reimbursement. She will discuss how to identify incomplete documentation, and the legal ramifications of incorrect documentation. This session will include a review of actual documentation to identify examples of common errors in medical record documentation. This is a must-attend session for physicians, coders, office managers and auditors who want to better understand the pitfalls all medical professionals face in their clinical documentation efforts, and how to improve their practices and get paid on time.
