Learn Documentation & Coding the Easy Way
November 21, 2008
One of the biggest responsibilities in health care practice is documentation, coding and billing. Documentation means all recording of patient care, billing, etc. It includes your daily patient encounters that build into the patient’s permanent record (file) in your office, and this documentation is used to justify the procedures you are doing and the bills you send to the patient and/or insurance companies.
The requirements for documentation are always changing, and the need for good documentation are imperative in a practice, as poor documentation can get a practice in a lot of financial and legal trouble. It is important for a doctor to know the ins and outs of documentation and coding so they can train their staff properly and keep excellent records.
Coding the art of applying ICD-9 diagnosis codes and CPT® procedure codes to the patient’s case. Insurance companies use a language of coding in which each diagnosis has a code and each procedure has its own code. Based on this coding, the insurance company can tell if the treatment is appropriate for the diagnosis, modifies case limits based on the complexity of the diagnosis, etc.
In essence, good documentation gives a solid support to your coding, and good coding gets you paid. What’s not to like?!
There are several ways to learn how to do good documentation and coding. Seminars, books, trial and error… in the past I’ve discussed an essential book (ChiroCode Deskbook) that every office needs. Seminars can vary depending on who is teaching them. Some give very good information whereas others essentially teach you how to get yourself in a lot of trouble really quickly. Today, my email box showed me another option, which is perfect for students.
Renowned documentation expert Kathy Mills Chang (she presented at Cleveland’s Homecoming this year) has a 12 hour DVD/computer course available. Doctors can get CEU credit for this course, but as a student you can learn everything you need to know about documentation at your own pace from their leisure of your home computer. You can find out more about the course by following this link.
The course cover 6 hours of establishing medical necessity through case history, exam, tests and measures, goals, diagnosis and treatment plans, etc. Essentially how to effectively communicate what you know is wrong with your patient to the insurance carrier. Another 3 hours of the course is for Medicare Compliance, which is a vital topic to understand. The final 3 hours of the course have to do with practical principles for coding and billing, in other words, how to use the codes in day to day practice and get paid for what you are doing.
The course is for Apple or PC computers and costs $295, which is a steal for this type of content. You can’t put a price on good documentation and it is a huge benefit to you and your practice to know this information before you start practicing rather than after, when it is too late!
