HCPro, JustCoding Outpatient - 2016 Issue 44 (November)
Working with physicians to improve clinical documentation
November 22nd, 2016
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Article Overview
This article covers documentation improvement in physician settings, with emphasis on how coders and medical assistants can help capture more complete clinical details for coding, risk adjustment, and medical necessity support. It is written for coding professionals, HIM staff, and physician practice teams looking to understand broad documentation challenges, workflow opportunities, and the role of supporting staff in strengthening the record.
Why This Topic Matters
Incomplete physician documentation can affect code specificity, reimbursement-related workflows, risk-adjusted reporting, and medical necessity review. Understanding practical documentation-support strategies helps organizations improve record quality without relying solely on the physician.
What You Will Learn
- Why physician documentation may be incomplete for coding purposes
- How office workflows can support better capture of clinical details
- Ways medical assistants may help gather documentation elements
- How documentation quality affects specificity, risk adjustment, and medical necessity
- Why team-based documentation support can improve the record
Who Should Read This
- Medical coders
- HIM professionals
- Physician practice staff
- Medical assistants
- Clinical documentation improvement staff
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