Documentation errors happen when patients do not give a proper description of their symptoms, and the attending medical staff triages the patient incorrectly. Further, the physician interprets the symptoms incorrectly leading to complications and unfavorable outcomes for DME billing companies. What’s worse is that it is the durable medical equipment billing services providers who stand to lose if the documentation isn’t up to the mark, compounding the already tight payment environment, leading to crucial reimbursements being denied.
For example, the amount that will be reimbursed for “unspecified heart failure” is far less when compared to chronic combined systolic and diastolic heart failure indications. Under-coding such care visits without realizing the complexity levels of such conditions leads to heavy losses for a practice, which needs to be brought to the notice of staff employed by DME medical billing service providers. Proper documentation is essential for appropriate coding that can lead to exact reimbursements. Poor documentation can also lead to diagnoses or treatment misspecification which may end up with overpayments. Here are 5 ways to avert DME documentation errors.
1.Maintain Accuracy
Record-keeping should be neat and legible, with minimum abbreviations (these lead to misspecifications by coders), complete details about the beneficiary, exact date and time of every single encounter, any corrections or overwriting needs to be suitably notated and countersigned by the concerned clinician. It is better to double-check dictated reports or notes so that errors or omissions can be detected.
2. Relevant information only
Vague comments and irrelevant comments need to be avoided at all costs. DME medical billing companies will land in serious problems because of irrelevant and inappropriate information leading to documentation errors. The legal ramifications can be serious as well, when, for instance “no change” is written instead of specifying the factors relating to the patient’s condition that haven’t actually changed.
3.Complete Documentation
All medical records need to include complete documentation including right from general practitioners, clinics, hospitals and specialists. Switching from hard copy records to electronic records will facilitate better compilation and help reduce omissions. During processing the DME billing services providers need to stress the need for intra facility as well as inter-facility communication being maintained properly to ensure completeness of documentation.
4.Turnaround time
Timeliness is crucial, hence patient’s history and physicals need to be done with and signed within a time span of 24 hours after admission. Similarly, post operative notes need to be completed immediately after surgery is done, and the relevant operative notes need to be dictated and signed within the 24-hour timeline after any procedure is completed. The medical records need to be updated within 7 days of discharge of the patient. All these procedures will ensure that relevant information is recorded accurately leading to proper documentation.
Thus, ensuring documentation errors do not come in way of smooth flowing revenue, must be a priority for DME. This will lead to a profitable business.