Why “Neatness Counts” in Documentation

When it comes to medical documentation, you can’t use (or bill for) what you can’t read.

For example, in the inpatient setting, many hospitals request that providers with poor penmanship return to re-document or amend notes so that they are legible. This became especially important when, in October 2008, Medicare changed to medical severity diagnostic related groups (MS-DRGs), allowing hospitals to be reimbursed for severity and complexity of care as reflected by documented ICD-9-CM codes.

Many institutions have put in place special programs, where medical records are concurrently reviewed by a clinical documentation specialist (usually a registered nurse) to assist providers in identifying the most relevant illnesses based on physician documentation. This process potentially leads to increased reimbursement for the hospital and providers. Institutions that have initiated such programs have seen phenomenal increases in their case management index (CMI). Individual providers also have enjoyed the benefit of improved communication with hospital utilization staff, hospital coding staff, and their own coding staff.

Worth knowing: CMS stated in the 2008 IPPS Final Rule (Federal Register, Vol. 73, No. 161, Aug. 19, 2008, “Rules & Regulations,” p. 48448). “We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record.”

For instance, don’t settle for code 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled when 205.21 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled or 205.23 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled is more accurate and specific.

Whether you are working in the inpatient or office/outpatient setting, neatness counts. Being able to read all documentation provides many benefits, including improved patient care, improved legal liability, and optimal reimbursement.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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