123ArticleOnline Logo
Welcome to 123ArticleOnline.com!
ALL >> Health >> View Article

Coding News You Can Use: Documentation Essentials

Profile Picture
By Author: Nancy Rose
Total Articles: 53
Comment this article
Facebook ShareTwitter ShareGoogle+ ShareTwitter Share

Documentation holes will cost your practice thousands of dollars in denied claims. Your top priority is getting top-notch clinical documentation for your inpatient coders. The latest coding news is that physician query and communication is now paramount, and not just important.

To be sure your payments are on track, keep a track of up-to-the-minute coding news and see how your hospital's policies and procedures address the following physician documentation discrepancies and issues:


Documentation mistake 1: If it is clear to the physician, it will be clear to the coders.

Physicians may assume that coders can get what they need by, for example, looking at lab values or other test results. But according to national coding guidelines, coding staff cannot code from lab values, and they cannot diagnose. Coders need the narrative terms required to support key diagnoses.

Under the new MS-DRG system, the reality is that we need a lot more specific and detailed verbiage in the medical record to support correct coding.

Documentation ...
... mistake 2:
Someone else will fill in the blanks for you.

Don't let physicians pass the buck when it comes to proper documentation in the medical record. Coders can't just pluck support for their codes from anyone's notes in the chart. For example, information regarding malnutrition must come from the physician (or a physician assistant or clinical nurse specialist) - not from a dietitian.


Documentation mistake 3: Physicians drag their feet when coders' queries come their way.

This is a mistake - but not necessarily the physicians'. How physicians respond to queries for more information depends in large part on how knowledgeable they are regarding the coding process - and health information managers are responsible for securing that buy-in.


Don't put your practice at risk by staying behind the updates. Get the recent coding news, or your practice's revenue will suffer.

Total Views: 271Word Count: 311See All articles From Author

Add Comment

Health Articles

1. Surrogacy In 2025: What To Expect And How The Laws Are Evolving
Author: Surrogacy Centre India

2. Arnica As A Medicine
Author: Rade Radosavljevic

3. An Ultimate Guide To Surviving The First 48 Hours After Wisdom Teeth Removal
Author: Will Sievier

4. Understanding The Different Types Of Dental Implants
Author: Paulo Pinho

5. How Smoking And Alcohol Affect Wisdom Teeth Removal Recovery
Author: Paulo Pinho

6. White Star Dental Clinic – Your Trusted Partner For A Healthy Smile
Author: White Star Dental Clinic

7. How Long Do Invisible Braces Take To Work? What To Expect
Author: Charlie Wellish

8. Order Online Ayurvedic Medicine: Heal Naturally At Home
Author: ayushmedi

9. Impacted Wisdom Teeth: Symptoms, Risks, And Treatment Options
Author: Paulo Pinho

10. Get The Best Online Cake Delivery Mumbai Can Offer
Author: Loveandcheesecake

11. 5-day Apple Diet Plan For Effective Weight Loss
Author: Go Moringa Dietician / Nutritionist in Gurgaon

12. Dental Treatment For Nervous Patients At Kaa Dentals
Author: KAA dentals

13. Consult An Eye Specialist Doctor In Thane For Better Sight
Author: Anil Eye Hospital

14. Do Wisdom Teeth Affect Your Other Teeth? Understanding Crowding And Shifting
Author: Paulo Pinho

15. Motivation Is Simpler Than You Think
Author: Impaakt Magazine

Login To Account
Login Email:
Password:
Forgot Password?
New User?
Sign Up Newsletter
Email Address: