Hi Sahni
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I can name a few improper billing trends. Here are some.....providers not putting minutes down in medical record documentation for the day if using phone or telehealth processes, listing the assessment or dx codes then give details in discussion if illness, if doing follow up they should list what specific body organ or system checking with ROS, and be specific in telling which bilateral limb or organ system caring for. Also it does depend on what medical specialty treatments done in because some require differ documentation data(general medicine vs psychiatry vs orthopedics). Understanding incident to services vs split shared vs consultations documentation all done properly but in differ formats. Another thing you can do is look at insurance denials per provider by type of payer and medical specialties help you too. Is a modifiers 59 vs 51 vs XS required due to differ areas of body treated on. Are providers using the most detailed dx used for differ stages of diseases in the medical record. Some staged or differ level diseases are: CHKD, Hypertension, type of Fracture, various substance abuses , & Depression, Diabetes Mellitus, Heart/Cardiac conditions, Burns, Etc. Provider should distinguish in their notes if pt. has chronic conditions vs illness happened years ago by entering a date so medical coder can selected correct ICD10 code. Oh yes if pt. suffers a current injury ensure put date, how it happened and where in the medical record for the day.. Insurance companies will deny if this detailed data regarding injury is not put on record and claim.
Did I help you with this data? I hope so
Lady T