May 2019

May 2019

Documenting and Coding for Success

When reviewing coding and documentation, providers should strive to consistently improve their  accuracy and compliance. Documentation involves far more than just writing down a list of services. Proper coding can make or break your reimbursement. We find that creating checklists and cheat sheets  for each type of patient visit helps to ensure that all the proper criteria are met, and often saves the headache of denials later.

Let’s begin with documentation

Most patient visits are going to fall into one of three categories: Initial Visit or New Episode, Periodic Reevaluation, and Routine Office Visits. Creating a checklist for each of these will help prompt you to provide all the critical elements required for relevant and compliant notes. Here are some examples of what you should include when creating your checklist for documentation:

Initial Visit or New Episode

Your template should prompt you to include the following:

  • Patient history of each complaint… known as History of the Present Illness

  • Review of involved systems, like musculoskeletal and neurological, or any others that may be connected to the chief complaints

  • As applicable, the patient’s:

    • Past History 

    • Family History

    • Social History

  • Exam Findings for each area of complaint

  • Initial Assessment that includes prognostic and other complicating factors

  • Diagnosis to include all areas you intend to treat

  • Treatment Plan to include goals, both short and long-term, as well as frequency and duration

Periodic Reevaluation

Documenting the patient’s progress isn’t just important, it is required. The steps for documenting a reevaluation may seem very similar to that of the initial visit but should also include recording details that allow for comparison with your initial findings, so that you may demonstrate progress. When creating this checklist, be certain to add the following:

  • Historical assessment of patient progress

  • Exam findings that demonstrate progress, or the lack thereof

  • Professional assessment

  • Diagnosis updates

  • Treatment Plan revisions

 Include any indicators which point to the effectiveness of your treatment

Routine Visits

Routine visits occur throughout the process of executing your treatment plan and must include some specific elements, such as:

  • The patient’s own assessment of their function

  • Objective findings

  • Provider commentary regarding patient improvement and the need to continue the prescribed plan

On to Coding

ICD-10 coding requires precision. Therefore, it goes hand in hand with your documentation which must dictate and support the ICD-10 codes you choose. If your documentation is sloppy and not concise, it will cause you to utilize non-specific, or unclassified codes that will quickly raise red flags for claims adjusters. This will quite likely initiate an audit which may include risk of recoupment or fines.

While not every ICD-10 code is site-specific, many are - enough so that it would make sense to keep a cheat sheet of spinal sites/regions readily available when you are documenting. If you find that you’re uncertain about which ICD-10 code to utilize, you should be able to locate the answer easily within your documentation. If you cannot, it may indicate that your documentation needs improvement, and you should refer to the checklists referenced above. When your documentation is on point, the correct codes should be easily revealed.

By simply creating a few simple self-help tools, your documenting and coding will be on track and lead to success in no time!