Note Language & Denials: Using Precise Documentation to Avoid Delays
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.