Elevating Medical Groups ®

Overcoming the
Obstacles in
Physician
Documentation
and Coding
Accuracy

Physician Documentation & Coding Accuracy

Most physicians view coding guidelines at best a nuisance, and at worst as an impediment to delivering the best care. The guidelines for coding are complex and confusing. Typically, physicians have very little training or support in this important, but overlooked area.

It’s not unusual for physicians in the same practice to code differently. The provider who lacks confidence in his/her understanding of E&M coding will frequently err by under-coding their work. If under-coding becomes the norm, the practice significantly limits its revenue opportunity.

More than Lost Revenue

When the basic structure of the evaluation, documentation and coding process is threatened, several areas of the practice are threatened, too:

  • The failure to capture and code pertinent E&M activity diminishes the quality of the note and the overall level of communication for patient care.
  • Poor documentation increases medical-legal risk and the risk of RAC audit
  • Since strong documentation is the foundation for accurate ICD-10 and Hierarchical Condition Coding, poor E&M coding creates less accuracy at the next level of coding.
If a physician with an average of 3,500 patient visits a year under-codes just 10% of his/her encounters, it can result in $10,000 per year in lost revenue. Find out an appropriate increase in net revenue for physicians who have participated in one of MediSync’s coding programs, E&M CodeRight.

MediSync has made me be a more successful physician and has helped improve my personal life, my employees’ lives and our patients’ experience.

Dipika Patel, DPM
Centers for Foot & Ankle Care
 

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