Try These Coding Compliance Strategies for Your Organization’s Clinical Documentation Improvement & Bottom Line

Try These Coding Compliance Strategies for Your Organization’s Clinical Documentation Improvement & Bottom Line

Medical coders translate a patient’s visit into a list of codes that allow payers to easily understand the patient’s experience. As one of many clinical documentation improvement strategies, coders should identify and code all pertinent information using applicable coding and billing guidelines. This ensures that all codes are present, accurate reimbursement is given, and the patient receives optimal care.

Healthcare organizations need to put the focus back on medical coding compliance. They also need to offer their teams effective strategies to get coding inaccuracies and inefficient claims management under control.

Top Coding Compliance Strategies to Try This Quarter

Seek to improve the quality of clinical documentation.

Without complete, accurate clinical documentation, coders cannot perform their duties.

clinical documentation improvement

Improving this area remains one of the biggest challenges for providers. However, hiring an in-house clinical documentation improvement manager – or outsourcing an external vendor, like YES HIM Consulting – can have a great impact. The ideal candidate needs to be a skilled coder with knowledge of clinical practices. They should work together with the provider’s departments to analyze their documentation methods and find opportunities to enhance them.

If hiring or outsourcing a specialist is not an option, you can still make improvements. To improve their coding abilities, providers can review various templates found in computer-assisted coding programs, the EHR system, and other coding resources offered by organizations such as AMA and CMS.

Enlist technology to streamline documentation practices.

Healthcare firms are utilizing technology to streamline other processes in the healthcare setting. Organizations can also apply this to coding. Computer-assisted coding solutions extract pertinent patient information from records and present it to the coder. Ninety-four percent of organizations that use computer-assisted coding solutions would purchase the technology again (KLAS Research, 2019).

These type of solutions can also help coders prioritize the accounts and sort through them by different factors, such as DRG or payer. The program can further identify which accounts need additional documentation, too.

Lastly, EHR systems should be re-examined to ensure they are compliant with the latest updates, and require all the necessary documentation to aid the coding and billing process.

Offer ongoing education for providers and coders to enable collaboration between departments.

Coders also need regular education to remain compliant with the annual coding updates. Developing a custom coding education plan will ensure they get the education they need on a timely basis.

Providers don’t need to be instructed on how to deliver care. However, they do need to understand proper clinical documentation improvement strategies so they capture all the necessary information during every patient visit. Teaching them why it is important to correctly document patient encounters will show them not only how that contributes to the coder’s duties, but to the long-term success – and bottom line – of the organization.

Working with an external clinical documentation improvement company can help establish these compliance practices and more. Contact YES HIM Consulting’s team of coding and auditing experts today to get your healthcare organization back on track.

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