The Value of Accurate Documentation in Medical Bill Reimbursement by medicalbillers


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            The Value of Accurate Documentation in Medical Bill Reimbursement

       Medical documentation has myriad applications in today’s health care administration – being reference-
       source for future encounters; enabling coordinated care, both within and across the clinical network;
       contributing to macro health care planning and reforms; ensuring clinical data privacy and security as per
       HIPAA norms; and ensuring flawless medical billing. Notwithstanding providers’ effort to document as best
       as they can, “accuracy” continues to be a matter of great concern. While inaccuracies in medical
       documentation can lead to lapse in medical care quality and breach of trust, it is the reimbursement that will
       be most affected.

       Every reimbursement starts with medical billing, which is calculating the cost of administering medical
       services. Clinical documentation – which contains physicians’ narration of entire course of medical
       management – is the source on which billers rely upon in assigning monetary value to medical services.
       Because most of the physician documentation is supposed to be true, medical billing is as good as your
       clinical documentation. But, physicians, with all their good intention and focus, may not always be expected
       to document without omission or error. And any omission or error may either correspondingly reduce
       reimbursement or expose your bills to chances of denial or delay.

       One way to do away with omission or error is to encourage doctors to check back on every chart before they
       move on to the next patient. But doctors are seemingly busy, and may not wish to keep the next patient
       waiting or compromise on clinical priorities. In such cases, internal staff may be assigned with the job of
       elaborating the doctor’s notes into comprehensive charge sheets or case summary. Training and orienting
       the so deputed staff is crucial before they take over the charge and start feeding medical billers with charge

       Clinical documentation has undergone remarkable changes recently – paper-based charts have given way to
       automated documentation. Medical practitioners are lot happier with pace and ease with which modern-day
       systems can generate voluminous reports that can easily be exchange across the health care network
       system. But, automated documentation is also inherent with investment, implementation, and training
       issues. Moreover, patient security and privacy may be at a higher risk from hacking concerns. All these issues
       may prompt the intervention of competent medical billing service providers who know how to upgrade
       providers’ internal clinical documentation in sync with medical billing and coding. – known for its catalytic role in clinical and operational management of a
       majority of medical practices across the 50 states – is prepared for the next challenge: changing face of
       clinical documentation in ICD-10 and HIPAA 5010. With the entire provider-fraternity transiting to a more
       robust, comprehensive, and technology-driven clinical documentation environment, it hopes to own up the
       responsibility of transformation. It is well-served by its core group, comprising clinical documentation
       specialist, expert medical billers and coders, and strategic partnership with best-known vendors of
       automated documentation systems. The fact that it has already executed documentation upgrading as part
       of its comprehensive RCM services is a testimony to its credential and competence.

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