Tag: Clinical Documentation

Next Level Coding Begins with Improved Documentation

Incomplete or vague documentation can lead to a major loss in billable revenue. By making sure you include the 4 following details in every dictation, Coders can determine the correct level codes are claimed so that you are reimbursed adequately.

The Vital Role EMR Plays in Medical Billing

    When the American Recovery and Reinvestment Act was approved, all healthcare providers (both public and private) were required to adopt the use of electronic medical records (EMR). Since January 1, 2014, EMR systems have assisted several healthcare organizations in maintaining health-related information on patients, as well as improving workflow and the quality of…

Validate Care Quality via Procedure Documentation

Clinical documentation is at the core of every patient encounter. It is to document the care provided to the patient, as well as to communicate with other providers. In order to be meaningful, it must be accurate, timely and reflect the scope of services provided.   Elaborate on Quality of Care Make clinical documentation improvements…