Accurate and complete documentation helps physicians avoid denials.
Diagnosis codes convey the reason for the visit, and they also capture risk-something that many payers increasingly consider when calculating reimbursement. It’s important for physicians to ensure that the information they document is as specific and complete as possible, said Terri Thomas, RHIA, clinical documentation specialist in San Leandro, Calif., who spoke during a recent national coding conference.
Accurate and complete documentation ultimately reduces denials, said Thomas. Translation? Physicians retain the revenue they generate.
Unspecified diagnosis codes often wreak havoc on cashflow because many payers simply deny them, said Thomas. “We need to be as specific and compliant as possible. That’s one of the reasons why we moved to ICD-10,” she said.
Thomas discussed these four diagnoses and provided checklists of what physicians should document to avoid denials:
1. Chronic obstructive pulmonary disease
2. Congestive heart failure
Physicians must ensure that they document all conditions that coexist at the time of the encounter that require or affect treatment. Coders are obligated to query physicians when documentation is conflicting, ambiguous, or incomplete, said Thomas. Physicians can mitigate these queries and protect revenue by taking the time to learn the specificity that’s required for code assignment.