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tci General Surgery Coding Alert - 2023 Issue Q2

Practice Management: Query Providers This Way to Improve Documentation

Focus on guidelines for complete records. You know that clinical documentation is key to accurate coding and reimbursement, but did you know that it also supports clinical outcomes, protects in malpractice cases, and helps with patients’ understanding of their medical story? Don’t let poor recordkeeping mangle your patients’ outcomes or your surgery practice’s earned reimbursement. Use these helpful guidelines for reviewing patient records and respectfully querying clinicians when you need to have them bolster documentation in the medical record. Use CMS Guidelines for Proper Documentation The Centers for Medicare & Medicaid Services (CMS) stresses that a valid...

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