Revenue Trifecta: Coding, Billing, Documentation

Many providers have seen a significant increase in claims delays and outright denials. The reasons may be many, but focused attention to three major elements can improve your results. Documentation, Coding & Billing work together to support adequate reimbursement. Weaknesses in any of these areas will affect the ability to capture optimal revenue.

Documentation is the Foundation of Every Patient Encounter.

• Record pertinent facts, findings, observations about past & present illnesses, examinations, tests, treatments and outcomes
• Documents the care of the patient
• Facilitates planning immediate treatment
• Monitor patient’s healthcare over time
• Tells the patient’s story

Strong Documentation drives the coder’s ability to capture all conditions that are relevant to the current encounter. The primary reason for the encounter must be clear. Secondary conditions that require management or affect the current encounter should be addressed by the provider. Problem lists can be misleading. Is the condition current or a historical occurrence no longer requiring treatment?

Documentation and coding will support accurate claims billing serving to decrease the liklihood of payer delay or denial. These 3 functions are strongly intertwined. It is imperative that providers and staff collaborate to protect revenue, reduce reworking of the claim, and maintain a strong cash flow.
Patient satisfaction is heavily influenced by the provider’s proficiency in obtaining correct and timely payment.

Target Audience

• Chargemaster Maintenance Staff
• Physicians
• Practice managers
• Medical assistants
• Nurses
• Compliance staff
• Billers
• Coders
• Revenue Cycle
• Risk Management
• Charge entry staff