Ambulatory Coding and Documentation

AMBULATORY CODING AND DOCUMENTATION PRESENTATION

Are your current coding and documentation practices up to par with the latest guidelines?

In the upcoming months, the STQN staff will provide a coding and documentation presentation focused on updating your practice on current coding and documentation requirements. Optimized coding and documentation are essential to respond to the changing expectations and provides an accurate description of clinical conditions. It also aids in quality measures for public reporting and reimbursement. 

Below are the highlights of the presentation:

Payers of healthcare services are changing the methodology for reimbursement calculation which makes coding one of the most essential pieces of information on an encounter claim form. Diagnostic codes must be precise and coded to the highest level of specificity to describe an accurate picture of the patient’s condition. Providers should report all diagnoses (not just primary diagnosis) that impact the patient’s evaluation and treatment. 

What is Risk Adjustment?

Risk adjustment is a statistical process that takes into account the underlying health status of a population, such as enrollees in an insurance plan, while looking at their health care outcomes or health care costs. The risk adjustment process allows comparison of performance across organizations, practitioners, and communities.

The risk adjustment model is used to predict mortality, severity of illness and health care costs based on the relative actuarial risk of the population that is being cared for by physicians. This risk adjustment program provides for adjusted payments to providers and insurance plans that attract higher risk populations including individuals with chronic conditions. The Affordable Care Act Section 1343 provides for risk adjustment to be a permanent part of the Medicare program.   

Coding Terminology

Accurate coding requires physicians to learn a language that allows for the translation of bedside care to administrative claims. Definitions and examples will be provided on ICD 9, ICD 10, CPT, CPT II and G codes as part of the presentation. 

Medical Record Documentation

Medical record documentation has to be clear, concise, consistent, complete and legible. For example, a common documentation error is to use “history of” for conditions that are actively being treated and not to code for chronic conditions.

Examples of correct documentation, coding guidelines, sample coding language and case studies will be provided in the presentation.