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tci ED Coding & Reimbursement Alert - 2023 Issue Q2

Compliance: Get Documentation Ducks in a Row Before Filing Claim

Here’s why open communication between providers, coders is vital. The difference between a clean claim and a denial usually comes down to one thing: documentation. Sometimes, your job as a coder is to identify whether the documentation in a patient record is complete and seek out additional information as needed. However, that’s not as easy as it sounds. Why is documentation important? Payers and auditors look for supporting details that prove medical necessity and appropriate ED evaluation and management (E/M) levels. But patient medical records are not only critical to fair reimbursement; they also contain the information...

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