Documentation: How to Learn What the Doctor Didn't Note
Medical Documentation is vital. Providers must provide accurate, adequate and clinically useful documentation of patient encounters in order to ensure continuity of care for the patient, useful communication between providers in the care continuum and to provide a solid basis for reimbursement of claims.
Coders and auditors are tasked with reviewing records to determine that provider documentation supports the codes that are submitted for reimbursement. This review process may occur before or after claims are submitted. Presubmission reviews reduce revenue cycle and maximize reimbursement, providing the opportunity to address common errors of omission or comission. On closer inspection, reviewers may identify opportunities for improvement or potential for risk to the organization. This presentation offers the opportunity to hear a physician’s take on documentation, the challenges of changing behavior and insights to make both more successful.
You Will Learn:
- How physicians feel about the medical record, and how to encourage them to improve documentation
- Identify opportunities for improved reimbursement
- How to address potential risk areas when reviewing records
- How risk adjustment and HCC coding depend upon documentation
- How to tear apart medical records to identify key components
CEU approved for all CPCs, CPC-Hs, and CPC-Ps.
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About The Presenter
Dr. Lynn Myers is a Family Physician and was in private practice for twenty years before moving into the role of physician educator for a large multispecialty group in North Central Texas. She is a certified coder, and works to help physicians improve their documentation in order to confidently support the levels of service and diagnoses reported for reimbursement. Dr. Myers is also certified in Healthcare compliance, and is the Physician Champion for implementing and meaningfully using electronic medical record systems for Texas Health Physicians Group.
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