Greensburg Medical

Memo
To:

Office Administrators

From:

[Your Name]

cc:

[Recipient(s)]

Date:
Re:

Importance of Documentation and Coding

Some of clinical workers ignore and resist having the discussion of the
relationship of the HER to reimbursement, thinking it may be the responsibility
of the billing department, this is not the case. Insurance plans audits follow
dictum, which means if it is not documented, it was not done. This means that
it does not matter how long the patient and medical assistant discussed the
patients problems, how good the doctors diagnoses was, or how thoroughly
the nurse assessed the patient, if it is not documented with sufficient detail in
the patients chart, the auditor assumes it was never done, or those parts of
the visit never happened. There is a direct relationship between the
completeness of your clinical documentation and the financial well-being of
your medical facility. If you are able to understand the relationship, you will
make sure that the information is completed with great detail. HIPAA law
regulates not only the privacy and security of health records, but they also
have established standardized healthcare transactions and require the use of
ICD-9-CM, CPT-4, and HCPCS codes sets. The ICD-9-CM codes justify and
explain the medical reason for the services being billed. ICD-9-CM are used
daily because they are required for insurance claims. Reimbursement for
impatient hospitals is based on Diagnostic Related Group (DRG) determined
from the primary and secondary diagnoses provided by the attending
physicians. For both outpatient and inpatient facilities the correct use of ICD9-CM is very important. ICD-9-CM allows for the correct code to be
automatically translated for billing purposes. CPT stands for current
procedural terminology, fourth edition. HCPCS stands for healthcare common
procedure coding system. CPT-4 is incorporated into the HCPCS. HCPCS was
developed by the CMS to code for supplies, injectable medications, and blood
products. These codes were developed and are maintained by the American
Medical Associate (AMA). It is important that everyone do their part in
documenting the patients care from the beginning of the visit, making sure we
are verifying information and documenting it correctly for billing purposes.

References
Electronic Health Records: Understanding and Using Computerized Medical Records,
Second Edition, by Richard Gartee. Published by Prentice Hall, 2012.