Medical documentation has myriad applications in today’s health care administration – being reference-source for future encounters; enabling coordinated care, both within and across the clinical network; contributing to macro health care planning and reforms; ensuring clinical data privacy and security as per HIPAA norms; and ensuring flawless medical billing. Notwithstanding providers’ effort to document as best as they can, “accuracy” continues to be a matter of great concern. While inaccuracies in medical documentation can lead to lapse in medical care quality and breach of trust, it is the reimbursement that will be most affected.
Every reimbursement starts with medical billing, which is calculating the cost of administering medical services. Clinical documentation – which contains physicians’ narration of entire course of medical management – is the source on which billers rely upon in assigning monetary value to medical services. Because most of the physician documentation is supposed to be true, medical billing is as good as your clinical documentation. But, physicians, with all their good intention and focus, may not always be expected to document without omission or error. And any omission or error may either correspondingly reduce reimbursement or expose your bills to chances of denial or delay.
One way to do away with omission or error is to encourage doctors to check back on every chart before they move on to the next patient. But doctors are seemingly busy, and may not wish to keep the next patient waiting or compromise on clinical priorities. In such cases, internal staff may be assigned with the job of elaborating the doctor’s notes into comprehensive charge sheets or case summary. Training and orienting the so deputed staff is crucial before they take over the charge and start feeding medical billers with charge notes.
Clinical documentation has undergone remarkable changes recently – paper-based charts have given way to…