What are the best practices for accurate and complete documentation of patient services?

1 Know the coding rules and guidelines

Coding is the process of translating the clinical documentation of patient services into standardized codes that are used for billing and reporting purposes. Coding rules and guidelines are established by various entities, such as the Centers for Medicare and Medicaid Services (CMS), the American Medical Association (AMA), and the World Health Organization (WHO). They specify the criteria, definitions, and conventions for assigning codes to different diagnoses, procedures, and modifiers. You should be familiar with the coding rules and guidelines that apply to your specialty, setting, and payer, and update your knowledge regularly to reflect any changes or updates.

2 Use clear and specific language

The clinical documentation of patient services should be clear and specific enough to capture the patient's condition, history, assessment, plan, and outcome. It should also reflect the level of service, complexity, and medical necessity of the care provided. Avoid vague, ambiguous, or incomplete terms, such as "stable", "normal", or "as above". Instead, use precise and descriptive language, such as "blood pressure 120/80 mmHg", "no signs of infection", or "continue with current medication regimen". Use approved abbreviations, acronyms, and symbols only when necessary, and make sure they are consistent and standardized.

3 Include relevant details and evidence

The clinical documentation of patient services should include relevant details and evidence that support the coding and billing of the services. For example, if you perform a procedure, you should document the indication, location, technique, findings, complications, and outcome of the procedure. If you prescribe a medication, you should document the name, dosage, frequency, route, and duration of the medication. If you consult with another provider, you should document the reason, mode, and summary of the consultation. You should also document any modifiers, such as time, laterality, or multiple procedures, that affect the coding and reimbursement of the services.

4 Review and verify the documentation

Before submitting the documentation of patient services for coding and billing, you should review and verify that it is accurate, complete, and consistent. You should check for any errors, omissions, discrepancies, or contradictions in the documentation, and correct them as soon as possible. You should also ensure that the documentation matches the codes and charges that are generated by the electronic health record (EHR) system or the billing software. If there are any discrepancies, you should resolve them with the coder, biller, or payer, and document the resolution.

5 Follow the legal and ethical standards

The documentation of patient services is not only a financial and administrative tool, but also a legal and ethical record of the care provided to the patient. It is subject to various laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act (FCA), and the Stark Law, that protect the privacy, security, and integrity of the documentation. You should follow the legal and ethical standards for creating, maintaining, and disclosing the documentation, and avoid any fraudulent, abusive, or inappropriate practices, such as upcoding, unbundling, or cloning. You should also adhere to the professional codes of conduct and ethics of your specialty and organization.

6 Seek feedback and improvement

The documentation of patient services is not a static or isolated process, but a dynamic and collaborative one. It involves multiple stakeholders, such as providers, coders, billers, payers, auditors, and regulators, who have different perspectives and expectations. You should seek feedback and improvement from these stakeholders, and use their input to enhance the quality and efficiency of your documentation. You should also participate in any training, education, or mentoring programs that are offered by your organization or professional associations, and learn from the best practices and benchmarks of your peers and industry leaders.