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 about quality! When improving clinical documentation, physicians should focus on the opportunity to validate and expand on the quality of care provided.
Markups Are Not Recognized Documentation
Fee tickets and superbill markups are not considered valid documentation and are not recognized in an audit. E/M levels, procedures, and diagnostic readings must be documented in order to reflect the quality of care and services provided.
Remember, If you did not document it, it did not happen!!!
Organizations need well-rounded individuals who can effectively articulate all the pieces:
- documentation requirements
- code assignment
- coding guidelines
- quality reporting
MEREM Healthcare Solutions can help!
Visit our website at Meremhealth.com for more information and be sure to take the opportunity to schedule a free consultation with Merem Health.