Many doctors are as intentional and unintentional coding mistakes have large ramifications.
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The Centers for Medicare and Medicaid Services (CMS) is extremely concerned about upcoding.
While there are many benefits to using electronic health records (EHRs), there is also a lot of room for error.
We help our clients learn to code accurately, before an auditor shows up at their practice.
Auditors can show up at any time, so it is important to prepare your practice. Typically, they are interested in several factors.
Auditors look at:
- Signatures, dates and times;
- Irregularities between history of present illness and review of systems;
- Strange wording or grammar errors; and
- Medically implausible documentation.
Sometimes, the fault is not directly due to the physician’s improper data entry, but rather a faulty template. It is essential to make sure your template is not leading to upcoding.
How can you make sure you are not upcoding?
Be very particular in your documentation. Be weary of copying and pasting.
Make sure your practice has policies and procedures to promote regulatory compliance and precise documentation.
Perform an internal audit or hire an outside auditor to come in to your practice and perform a review of your charts.
EHRs can be difficult, but physicians are still responsible for accurate coding.
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