Every time a patient has an encounter with a provider, there are billable codes that need to be entered their chart. It is important that the patient’s chart be coded correctly so that you do not forget to bill for what was done and so that you can remain in compliance with guidelines and standards of care. Here are three ways that medical chart auditing through this type of coding can benefit your facility.
Checking for Compliance
It is important for physicians, nurses, nurse practitioners, physician assistants, therapists and every other provider of patient care at your facility to be following the established guidelines for coding. Improperly coding a procedure could affect your revenue and the patient’s health. Incorrect coding could also result in erroneous charges and an unhappy patient. The auditing can look at coding compliance by individual care providers at your facility. Having accurate HIM coding displayed across a medical system is essential to maintaining accurate patient records.
The Centers for Medicare and Medicaid also have a lot of rules around coding. You can have the compliance auditors check your coding for those purposes. This is especially important if your facility cares for a lot of patients who participate in these healthcare programs. Your ability to receive federal funds could be impacted if you are out of compliance with the coding.
Demonstration of Clinical Documentation Improvement
Perhaps your facility has had a problem with clinical documentation in the past, and you created a plan to fix it. It is a good idea to have auditors check in order to see if your clinical documentation is getting better. Having the information in front of you allows you to continue making progress on compliance.
For more information about HIM coding, contact GeBBS Healthcare Solutions by phone, or visit the website.