Have the Diagnosis In Your Documentation

One of the biggest ways that physicians lost out on reimbursements is through poor documentation. Offices get hectic, notes you intend to make don’t get made and sometimes your medical billing claims get submitted to the carriers for reimbursement without the proper documentation.

First and foremost, there must be a diagnosis of the condition or disease for the patient. From that it must extend the services rendered in conjunction with the condition or disease and the medical documentation explaining why the services were performed. Only the physician can state the diagnosis for the patient, even with test results that clearly show for example a patient was diabetic, the person doing the coding can not assume a diagnosis even when it is clear. The physician can only document that information.

Most carriers will not pay a medical billing claim that lacks a diagnosis. Double-check your medical billing before you send it in to avoid this. If you and your staff are finding it hard to keep up with the amount of medical billing your office is generating or you find that your are only getting partial reimbursements or rejections of claims, it might be time to consider outsourcing your medical billing. You will find your reimbursements arrive in a couple of weeks instead of nearly a month and with someone on board that has the sole job of making sure your medical billing is done right the first time, you will get more revenue than ever before to run your practice.

View all Articles by: Melissa Clark, CCS-P