Note language is an aspect of the practice of medicine that bridges both the administrative and clinical sides of the house. As a responsibility, documentation falls on the priority lists of practitioners – doctors, physician assistants, or nurses. Yet the consequences of providers’ documentation decisions fall on their support staff of coders and medical billers, whose job is to get practices paid by insurers.
Note language is the ‘connective tissue’ between the patient encounter and the revenue cycle. Even for those physicians who are heavily reliant on charge tickets (or other forms and technology tools designed to make it simple for back-office teams to code an encounter), note language serves to guide diagnoses, treatments, and care coordination – and it’s vitally important in the event of any audits, quality reviews, or patient file requests.
Yet despite its significance to both care outcomes and the revenue cycle, many providers don’t adhere to best practices in the space. (If you’ve ever perused a selection of charts, you’ve probably seen a few eye-raising notes yourself.) Especially now that ICD-10 requires greater specificity in coding, precise and accurate note language is a medical practice’s best hedge against claim denials and delays due to resubmission.
The most clear example: medical necessity denials, which are typically due to improper documentation. While every medical necessity denial stems from a unique set of claim circumstances, they often result when a practitioner documents the encounter post-visit, from memory, rather than during it. When reconstructing the encounter after the fact, doctors and nurses often neglect to include all of the elements that make a treatment or procedure “medically necessary” (and without that information in the medical record, practices can easily end up in hot water with Medicare and other payers).
During the encounter, the provider should document the patient’s history, physical findings, all diagnoses, services performed, supplies used, prescriptions or tests ordered, and patient instructions. Many providers still rely on paper and pen note-taking, but dictation systems can make it simple for doctors to record all such information and have the audio converted into note transcriptions post-visit.
Whether it’s transcribed or typed into an EHR system, the patient’s medical record should also contain all the detailed and specific information that supports why the physician prescribed the procedure, especially if it’s because past treatment plans or efforts were unsuccessful.
To avoid medical necessity denials, many providers overcorrect – providing a wealth of unnecessary information on family history, for example, that’s irrelevant to the situation of the encounter at hand. That’s not the worst error a doctor can make, but it can slow down the coding process (by forcing coders to comb through a too-much-information note to pinpoint relevant charges and diagnosis info) or raise unwelcome questions in the event of an audit or other review.
Ultimately, the goals of both the clinical and administrative sides of a medical practice are intertwined: to deliver high-quality care, and to get the practice paid for it. As the link between those two objectives, accurate documentation is always worth the time and effort it takes.
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