Clinical Documentation 2016 - Conference on Clinical Documentation Improvement

Overview: Review 6 points of high quality evidence based clinical documentation Review of 7 criteria that all entries in a patient record should include Impact of documentation on coding and claims Impact on audits and ability to defend an audit
When an audit is initiated, the completeness of documentation becomes critical in the ability to support what you have reported. Let's take a look at areas in which weaknesses are often found.
Why should you Attend: The granularity and accuracy of the ICD-10 code set is supported by quality clinical documentation. It is anticipated that payers will increasingly become less flexible in allowing non-specific codes. The use of unspecified codes will likely lead to rejected claims if it is possible to report the more definitive condition. In most cases, unspecified should not be reported unless there is clear evidence to support the inability to report the detailed option.
Is your E & M level supported in the documentation? If you have never experienced scrutiny of your billing patterns by payers and other entities, you may not be aware of weaknesses that lead to recovery of funds or other costly consequences. Your documentation will be key in supporting diagnoses, service codes and acuity of the patient. It is not just payers who engage in audits. Others include State medical boards, Qui Tam and possible reporting of questionable practices by patients. Do your billing patterns and documentation stand up under reporting scrutiny? This presentation will review areas in which you may not be as strong as you think!
Areas Covered in the Session:
Significance of abnormal lab results
Measurement of lesions, when taken and inclusion of margins
Start & stop times & methodology for infusions & discrepancies in billing
Diagnostic testing and medications should be supported in a diagnosis
Depth of wounds and cause should be clear
Severity of illness
Diagnosis present on admission?
Who Will Benefit:
Coders
Billers
Revenue cycle
Physicians, mid-level providers
Nurses
Claims follow-up
Managers
Speaker Profile
Dorothy D. Steed is an Independent Healthcare Consultant and Educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician coding audit supervisor for another hospital system, with 38 years of experience in healthcare. Additionally, she is an instructor at a state technical college in Atlanta, provides auditing & training in both facility and physician services, and has been a speaker at several healthcare conferences.
Ms. Steed has written articles for several medical publishers and served as a contributing author for medical billing and coding training material. She writes online courses, and is an AHIMA certified ICD-10 trainer, both CM & PCS. Ms. Steed is credentialed in medical coding, medical billing, medical auditing.
Price : $139.00
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