Gain a New Perspective on Provider Documentation

Gain a New Perspective on Provider Documentation

When provider and payer work together, everyone wins.

By Marcia A. Maar, COC, CPC, CRC

Clean, accurate provider documentation improves reimbursement. To demonstrate, consider the ideal reimbursement process:

Certified Professional Coder-Payer CPC-P

  • A patient comes in for an office visit or service.
  • A provider documents the reason for the visit, which proves medical necessity for services provided on the date of service or future dates of service, if further diagnostic testing or treatment is needed.
  • Diagnosis and procedure codes are assigned, and a claim is submitted to the payer.
  • The payer receives the claim and passes it through clinical editing software for either approval (resulting in payment) or rejection (resulting in denial).
  • The payment and remittance advice or denial and rejection reason are sent to the physician’s office.

Let’s compare this ideal scenario with the all-too-common reality:

  • A patient comes in for an office visit or service.
  • The provider documents the reason for the visit.
  • Diagnosis and procedure codes are assigned, and a claim is submitted to the payer.
  • The payer receives the claim, but the code pair gets caught in a clinical edit and is rejected.
  • The denial and rejection reason are sent to the physician’s office without payment.
  • The provider spends time and resources to correct the claim and then resubmits it, probably to be rejected again because the documentation still does not support the service.

Accurate Documentation Is a Win-Win

Poor quality documentation affects patients, providers, and payers. It causes everyone time and money, and it distorts reporting to the Centers for Medicare & Medicaid Services (CMS) for risk adjustment data validation audits.

Accurate documentation allows for correct coding, which results in proper payment and seamless continuity of care. It also leads to more accurate risk adjustment data, which allows CMS to pay plans more appropriately. It’s a win-win for everyone involved.

How to Improve Provider Documentation

It’s important for providers to document a clinically precise diagnosis. This allows you to accurately capture the most specific ICD-10 code — one that supports the medical necessity of the service provided. Linking an appropriate diagnosis code to the correct procedure code(s) greatly reduces the number of legitimate claims that are rejected unnecessarily (e.g., repeat procedures rejected as duplicates).

Knowing your payers’ requirements regarding diagnosis/procedure code combinations can streamline claims processing from start to finish. If you’re unsure how to bill a specific service, reach out to your area payer’s provider relationship representative. They will be happy to explain how you should bill a specific service to ensure proper and expedient claims processing.

Examples of how payers use provider documentation:

• Medicare, commercial, and Medicaid risk adjustment

• Clinical editing disputes and utilization management

• To determine medical necessity

• Prior authorizations for medications and radiology services


Marcia A. Maar, COC, CPC, CRC, is an AAPC Fellow who works in risk adjustment for a local non-for-profit health insurance company in Rochester, N.Y. She is the president of Rochester’s local chapter, Flower City Professional Coders.

One Response to “Gain a New Perspective on Provider Documentation”

  1. Tricia Tumele says:

    Biller/coder used the wrong procedure code .this would also affect the process if they rebilled to soon before the 34th day of late payment.

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