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How Effective Clinical Documentation Protects Reimbursement

Most people understand how critical clinical documentation will be for regulatory compliance after the ICD-10 deadline, but few talk about how fundamental it will be for driving maximum reimbursement. Better clinical documentation will not only protect reimbursement after the transition, but it will also serve as an important step toward improving quality of care.

At a minimum, physicians will need to ensure that clinical documentation has the accuracy, completeness and granularity necessary to attain reimbursement while remaining compliant with regulatory and reporting standards. One challenge, however, is eliminating the need for physicians to take time from their workflows to fill in gaps in their documentation—specifically, filling in missing documentation for coders after the care has been provided.

Revisiting old charts is highly disruptive for physicians and comes with a great risk. The doctor must depend solely on his memory to provide missing details, which increases chances of errors. If he makes a mistake, this could impact the code and reimbursement. Nevertheless the coder must request more information, otherwise the physician and the hospital won’t get reimbursed at all. This issue will take on even more significance after the ICD-10 transition in October 2015.

Going to ANI 2014? Visit MEDHOST in Booth 218 for more information about the importance of clinical documentation on ICD-10 and reimbursement.

To find out how MEDHOST is helping hospitals and healthcare facilities of all kinds get to the forefront of the digital transformation, email us at or call 1.800.383.6278

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