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Question: I feel like providers are grateful for billers and coders for sorting through so much paperwork and making sure they get the payment they鈥檝e earned, but how do I underscore the importance of accurate documentation? What are some reasons I could give to providers to help them understand that the process of coding from documentation isn鈥檛 just for money, but for patient well-being, too?

South Carolina Subscriber

Answer: While providers, like most people, want to be paid for their work, any provider education about documentation should stay away from talk about reimbursement. Documentation is primarily a means of capturing a patient鈥檚 conditions and establishing and maintaining a health record that is comprehensive and accurate.

So, when you鈥檙e talking to providers about their documentation, especially if you鈥檙e doing so in hopes that they鈥檒l provider higher quality or quantity notes, focus on how documentation tells the patient鈥檚 story. Documentation is especially important because it can show the quality of patient care 鈥� and any lack of documentation can compromise a patient鈥檚 safety, if there鈥檚 a breakdown in the continuity of care.

If a patient gets transferred, or if a patient needs to go elsewhere for a higher level of care, continuity of care is crucial for other providers to be able to see everything. While coders depend upon documentation to report care in a standardized format 鈥� diagnosis codes, procedure codes 鈥� for reimbursement, among other things, patients depend on comprehensive documentation as a means of safety, to communicate their medical histories when they may not be able to.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC