Teamwork, Part 3 – Coding and Documentation

All Health Care Organizations are being threatened with Overpayment Audits, primarily due to insufficient or incorrect coding. Remaining compliant with coding and documentation requires a team effort.  Physicians, nurses, case managers, ancillary staff and coders all have to work together.  The coders can assist the key personnel by educating them with their understanding of proper coding and documentation guidelines.

At times, it is difficult to get physicians to comply with a documentation improvement program.  Creating a physician query system works well in having the physicians discuss any open items that are needed to complete the coding of the service. We have seen these systems successfully set up so the coding team can send coding/documentation questions directly to the physicians, with the physicians bound to respond to the coding team's inquiry within a certain period of time. The query can be used for missing diagnosis or procedure codes, co-morbidities or incomplete documentation for the codes provided. 

Working with a coding team that performs routine medical chart reviews and provides educational services for the physicians is key to physician compliance on a consistent basis.   Having an established relationship with the physicians allows the staff to have an open forum to educate them on ongoing proper documentation and quality of medical care.

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