ED Pro fee Documentations need to be short for coding

[sarang.ubale9pharmacist.com@gmail.com]

As per my experience in Emergency Department Pro Fee Coding. There are a lot of unnecessary documentation given almost by all hospitals. Why ? Coders get confused what to read & interpret. I believe that it can be made more simple way. AAPC should give or make a guideline for all ED pro documentation for Coder tab should be given given where only specific short notes will be given based on which coders can do coding fast, rapid with good quality. Example : Diagnosis: COPD, symptom: SOB, PMH: Active smoker, Hx obtained from: Wife. Labs performed: CMP, Troponin, BMP, PT, PTT, INR,. Imaging done: CT chest w/o contrast. Medication : Xyz....., like this short Coder tab should be given. Within this Productivity and Quality both will get enhanced. It can happen only when AAPC create such kind of guidelines so that people who make such documentation can know and make work easy.

 

[sls314]

As per my experience in Emergency Department Pro Fee Coding. There are a lot of unnecessary documentation given almost by all hospitals. Why ? Coders get confused what to read & interpret. I believe that it can be made more simple way. AAPC should give or make a guideline for all ED pro documentation for Coder tab should be given given where only specific short notes will be given based on which coders can do coding fast, rapid with good quality. Example : Diagnosis: COPD, symptom: SOB, PMH: Active smoker, Hx obtained from: Wife. Labs performed: CMP, Troponin, BMP, PT, PTT, INR,. Imaging done: CT chest w/o contrast. Medication : Xyz....., like this short Coder tab should be given. Within this Productivity and Quality both will get enhanced. It can happen only when AAPC create such kind of guidelines so that people who make such documentation can know and make work easy.

AAPC doesn't have the authority to dictate how hospitals or physicians document Emergency Department encounters. Documentation requirements are driven by patient care, legal and regulatory requirements, and accreditation standards.

Also, ED documentation serves a much broader purpose than just coding. It's the legal record of the patient's care and communicates important clinical information to the providers who will be caring for the patient after the ED visit.

AAPC members who work within health systems or physician practices can certainly educate providers on best practices for clear and complete documentation.

However, that's something done at the individual employer level. It's not something AAPC, as a professional association and credentialing body, can mandate or enforce across all healthcare providers.