Documentation Deficiencies – Common Steps to Improvement

The medical record is the cornerstone of every patient encouter.  The content is generally recorded once, but may be used repeatedly by different persons for a variety of reasons.  Problematic, conflicting and incomplete statements often lead to coding and billing errors that costs the provider money.  In this webinar, we will discuss criteria for quality clinical documentation, standards of documentation in the record.  Examples of problematic documentation will be included.

Webinar’s Goals

• Provide insight why documentation styles may cause claim denials.
• Understand how documentation deficiencies can lead to audits & investigations.
• Understand how critical omissions can cause reduction or denial of your reimbursement
• How to resolve when providers issue conflicting statements
• Diagnostic statements that are unsupported by clinical evidence

Target Audience

• Physicians
• Practice managers
• Medical assistants
• Nurses
• Compliance staff
• Billers
• Coders
• Revenue Cycle
• Risk Management
• Clinical documntation staff