Documentation:
Open Physician-Coder Communication Does The Trick
Published on Mon Jul 11, 2011
Be aggressive with your procedure/diagnosis queries for the sake of clarity.In diagnosis coding, transforming medical records into a numeric code for billing purposes may not be enough. Documentation is the basis for coding. Thus, you should take into consideration accurate documentation as critical to diagnosis coding.Risk: Deficient documentation could result in a payer's refusal to reimburse for a test or service you rendered.Make sure you and your physician speak the same language, so you can code at the highest level of specificity. Here are two tips to do just that.Tip 1: Ensure Clarity Between You And Your PhysicianYou should avoid 'ultraconservatism' in coding. Over the years, many coders have learned to break off from the practice of questioning the physicians when the documentation was not complete or was not clear to them. You and your physician should work hand in hand on going after better documentation -- as aggressively as you [...]