Your practice is responsible for providing care for your communities –– and beyond. At the end of the day, your bottom line dictates the volume and quality of care you can deliver. That’s why providers must take every step to secure their bottom line, which is accomplished largely by their documentation practices and protocols.
Thorough, accurate, and prompt documentation practices are foundational to the success of any medical practice. This article from Larsen Billing explores why documentation is critical to your bottom line and how you can ensure your documentation yields desired outcomes for your patients, providers, and practice.
Improved Quality of Care
Complete and accurate documentation by healthcare providers is essential to help improve the quality of care and support patient safety. Properly documented medical records can facilitate communication among clinicians and assist with continuing care.
Every clinician caring for a patient has access to their records. This access allows them to communicate with each other without verbally speaking with them. Additionally, thorough documentation helps to mitigate potential risks and malpractice claims. Your documentation is critical to positive patient outcomes and provider integrity.
Proper documentation practices have a significant impact on your reimbursement. The clinician’s documentation highly influences the efficacy of coding and the efficient processing of claims and should support the coding and billing of the services reported.
Clear and concise documentation is critical to your bottom line, as it reflects the patient’s clinical picture and tells the patient’s story, including the complexity of their visit. A highly complex visit with minimal documentation may not be valued appropriately from a coding and billing standpoint. And when that happens, you won’t be compensated for the time, effort, and expertise you provide.
Streamlined Provider Workflows
Over the past few years, changes in evaluation and management (E/M) guidelines have reduced documentation burdens on providers. Previously, providers were expected to document certain elements in their history and exam, which impacted the code level selection. If these documentation elements were not met, the services might not have been valued appropriately, regardless of the risk involved and the complexity of the visit. Regardless of the circumstances, the chart wasn’t valued appropriately if providers didn’t document enough elements in their exams.
But now, the volume requirements have changed for clinician documentation, reducing the overwhelming burden of paperwork laid on providers. The E/M guidelines now only require a medically appropriate history and exam, freeing providers to focus more on patient care and managing their patient’s conditions. Instead of allocating time to count elements as they record them, providers can document what is pertinent and direct their energy and focus back to the patient.
Segmenting Service Codes According to Provider Documentation
Although the burdensome history and exam element counting are gone, the provider must still thoroughly document the chart to support the medical decision-making (MDM) and/or the time involved during their visit.
Providers can code visits based on MDM or time for outpatient office visits. Regardless of your choice, you must have enough documentation to support the visit. Below we segment services based on their coding.
Services Coded Based on Medical Decision-Making
Services that are coded based on MDM should include the following elements:
- The number and complexity of problems that are addressed during the encounter
- The amount and/or complexity of data to be reviewed or analyzed. This data would include information that must be reviewed, obtained, ordered, and analyzed for the encounter.
- The risk of complications and/or morbidity or mortality of the patient management
Services Coded Based on Time
Services that are coded based on time should have the total time (in minutes) clearly documented. Total time includes the following:
- Preparing to see the patient (e.g., reviewing external test results)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient, family, or caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health records
- Independently interpreting results (not separately reported with a CPT code) and communicating results to the patient, family, or caregiver
- Care coordination (not separately reported with a CPT code)
- Elements not included in the total time
- Performance of other services that are reported separately
- Teaching that is general and not limited to the discussion that is required for the management of a specific patient
Securing Your Bottom Line with Larsen Billing
Understanding how to correctly document care and submit claims is central to the health and longevity of your practice. Accurate coding and filing ensure you are compensated the total amount you deserve for services rendered. That’s why you must document care correctly, thoroughly complete coding and billing, and file claims promptly.
At Larsen Billing, we know our providers are juggling many responsibilities. Every moment of your day is full between patient care and running your practice, leaving little time for researching coding updates, double-checking claims submissions, or rethinking documentation workflows and optimization. And when you can’t devote your full attention to your billing and coding, things slip through the cracks, claims are rejected, and your bottom line is negatively affected.
Larsen Billing’s team of coding and billing experts ensures that every piece of your documentation is accurate and complete and that your claims are submitted correctly and on time. We stay up-to-date on updates and changes in E/M guidelines, ensuring your claims return the highest compensation for services provided. We can audit a sampling of your charts and conduct a provider education session to help teach your providers how to improve their documentation to better support care.
At Larsen Billing, we are personally invested in your success. Our team provides one-on-one support and meticulous attention to detail required for successful claims submission, credentialing, and contract negotiation. We are here to support providers and their practices so you can continue caring for your communities while we handle your coding and billing.
Reach out to the team at Larsen Billing today to learn how we provide documentation support and guidance that empowers your entire practice –– and those under your care –– to thrive.