The importance of comprehensive documentation of patients’ health records cannot be understated. This is an issue that not only influences patient care but also impacts the financial well-being of any dermatology specialty.
Significance of Documentation in Dermatology Practices
Dermatology practices which do not follow high documentation standards will have troublesome consequences. Appropriate documentation of records and health care claims submitted to payers leads to processes being performed perfectly, thus improving the financial stability of the practices.
The medical record that has been directly entered by a physician or dictated and transcribed, forms the basis for understanding the chain of events that occurred, informing third party payers about what processes have been performed and what services were provided. Moreover, certified and experienced medical billers and coders are aware that something that has not been documented has not happened. Appropriate coding can be achieved only when entries in the patient health record are translated accurately.
The Coding-Documentation Connect
Medical coding language is precise. Codes can be assigned only when being supported by documentation. This necessitates complete documentation that offers all relevant information. In dermatology practices, while dermatologists examine their patients, it is essential that they make their observation clear. Minute details such as the location of the examination and findings need to be documented clearly. These details impact the diagnostic as well as procedure coding. Location and size of lesion have to be explicitly described.
Standards Required in Documentation
It is not just the back office’s concern to adhere to documentation standards for accomplishing accurate coding and proper reimbursement. These standards need to meet the expectation of any health care provider who is unfamiliar to the patient. Patients’ past history and treatment details function as guide for their future health management. This is the reason why dermatologists review patients’ history during every encounter.
Thorough Documentation leads to Smooth Reimbursement
With thorough documentation of records, assigning codes becomes easier, thus facilitating submission of clean claims. Need for appeals toward reconsideration does not arise. During payer audit, health care claim can be compared with the documentation; this helps in determining whether proper payment has been received by the dermatologist for the services provided. In the event of the documentation not reflecting what has been described in the claim, the treating dermatologist will get reduced payments and may be liable for potential penalties.
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