Podiatry Coding & Billing Alert

Here's why your legibility matters.

Because of the nature of ICD-10-CM's injury and musculoskeletal codes, you've got to be extra vigilant about podiatry clinical documentation. The danger isn't only to your bottom line. You could run the risk of medical review, down-coding, and even fraud investigations.

Background: ICD-10-CM's increased procedural specificity yielded a large number of improper claims due to documentation problems in 2015, according to the Centers for Medicare and Medicaid Services 2015 improper claims report. According to the report, "the most common cause of improper payments (65.4 percent of total improper payments) was a lack of documentation to support the services or supplies billed."

"Clinical documentation is the foundation of every health record," says Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga. Clinicians may collect documentation only once, but others will use it many times so it's important to make every effort to prevent it from being misunderstood.

"Documentation and coding go hand-in-hand," Steed told Podiatry Coding Alert. The "coder needs high-quality documentation to determine coding quality and accuracy."

Follow these seven guidelines to guarantee quality clinical documentation, and consider how your office's providers can improve to support your coding efforts.

1. Pay Attention to Legibility

Documentation should be readable and easily deciphered. A lot of handwritten documentation isn't legible or decipherable, Steed cautioned. Rushed or careless documentation may cause other problems.

Legibility includes being able to read the name and title of the clinician completing the documentation. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient's condition.
• Jeopardized reimbursement.
• Denied payment.
• Loss of legal appeals.
• Serious patient injury.

2. Remember Reliability

Ask these questions: Is the documentation trustworthy? Based on the diagnoses, is the documentation reliable? Does it support the rationale for the diagnoses and for medical necessity?

The reliability is related to every single visit note. Most denials and down coding occur when visit notes don't support the codes you report based on the original assessment.

3. Be Precise

Clinical documentation must be accurate, exact, and strictly defined. Increased detail generally means greater accuracy in documentation, Steed said.

4. Complete the Concerns of the Record

Good documentation fully addresses all concerns in the record, and includes appropriate validation.

5. Maintain Consistency

Documentation shouldn't be contradictory. Are there conflicting statements in the record? Are there conflicting opinions between providers that have not been clarified? Make sure any inconsistencies are addressed.

6. Take Away Questions by Being Clear

Documentation should be unambiguous. Vague documentation that does not totally describe a patient's condition won't support the services your agency provides.

7. Factor in Timeliness

Documentation must be up to date to help ensure optimal patient treatment.