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 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.

MEREM Healthcare Solutions is a Birmingham, AL-based company that has been providing exceptional medical billing and coding services to physician practices and ambulatory surgical centers since 2008.
We pride ourselves on not just maintaining, but exceeding, the level of accountability, communication, and customer service that is valued in traditional, on-site billing departments.

Please check out our other blog posts, or contact us to learn more.