With the medical billing and coding industry evolving and changing at an unprecedented rate, the focus has shifted from simple (paper?) to complex and complete documentation – be it on the clinical or process side. As and when new changes get announced, there is more and more emphasis on the necessity for proper documentation.
Many consider documentation a pain and fail to understand the importance of it. It may not be required immediately, but it can be safely presumed that it would come in handy at a future point in time. Let me highlight some instances where proper documentation is not only an option but a must-have.
Insurance Auditing:
The most frightening nightmare that a practice can have is – the insurance audit. With the advent of the RACs, MICs and ZPICs, every Healthcare entity is at risk of being audited and penalized. The only solution that can alleviate this problem a little is by having proper documentation. Also, the Appeals data of the past 2 years show that Healthcare professionals with complete and proper documentation had a very high success rate when they appeal the ruling made by the Auditors. It certainly pays to be methodical and careful with documentation instead of losing both past and potential future revenues to Audits.
Accurate medical billing and coding:
Documentation is the key to accurate billing and coding. Many entities follow the simple rule – ‘If it is not documented, it cannot be Coded or Billed’. This policy is followed not only to promote ‘Best Practices’ in Billing, but also to avoid later complications during Audits. Any omission of details while documenting can lead to under payments and/or even denials. Many Providers realize the extent of revenue loss incurred by them due to poor documentation, only when they go through an audit of their past claims. Moreover, ICD-10 being much more detailed in its Code-sets, demands clinical documentation to be precise in order to get accurate payments.
Process Improvement:
Process improvement and re-engineering are the key to evolve with the changing times for any process, including medical billing and coding. Failure to improve or re-engineer processes in accordance to new guidelines and rules, results in denials and underpayments which ultimately lead to the demise of the entity. There have been several instances where Healthcare institutions declared bankruptcy just because of inefficient processes, improper documentation or an inability to change with the times.
Appeal for denied claims:
Appeals work at two levels, with the Insurance payer as well as when being Audited by RACs, MICs or ZPICs. When the documentation is good, denials can be re-filed and appealed with more authority which results in faster and higher payments. Once a track record for excellent documentation is established, the Payers accede to review requests faster.
Reporting & decision making:
Clinical documentation supports medical research by providing all essential information and has been very helpful for healthcare agencies like the CDC and DHHS in disease management and faster decision making. The case of the H1N1 virus is a good example of how proper documentation helped the agencies in responding promptly with advise and treatment protocols.
The need for documentation in medical billing doesn’t end with this short list. Every process in medical billing and coding needs proper and complete documentation that can help in the filing of clean claims and improve reimbursements.