tci Outpatient Facility Coding Alert - 2015 Issue 1

Documentation Tactics: Here's Your Primer on Necessary Documentation for Each Stage of Care

Remember: If it isn’t in the chart, it can’t be billed. Every coder knows that your physician’s notes should match the codes being billed. Developing and nurturing good collaboration between everyone involved (physicians, billing professionals, and health information management groups) is one of the best steps toward clean claims. Read on for advice on smoothing the information pathway between groups. Ask 2 Key Questions About the Documentation Before you can select a code, you need to verify two important things regarding the provider’s documentation. Does the documentation support the level of service (LOS) billed? The...

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