A Simple Lack of Documentation

One of the biggest reasons for denied claims or missed charges on your medical billing is simply a lack of documentation. It is never intentional, but in these busy days of patients, phones, and crisis du jour, it happens. Some of the important processing points where this can happen with your medical billing are:

At the Point-of-Care: This is one of the most common causes for inaccurate or lost billing is that doctors find it difficult to record all patient encounters at the end of the day. It’s hard to recall every single procedure you performed with what patient. Your medical billing partner can consult with you to help you create a personalized system where you will be able to record services rendered at the point of care. Through capturing software and other methods to help you track your services, your errors and omissions in your practice’s billing will be greatly reduced and in many cases, eliminated.

Too many times, in a busy practice, multiple care givers will see your patients and sometimes charges get missed due to interruptions, telephones ringing and day to day activities that sometimes stop the work flow. Your medical billing partner can help you devise a plan around this scenario to make sure all procedures performed get coded and billed.

Another way to simplify your process is to have your most commonly used CPT codes handy and quickly jot them down or use an electronic capturing system (many are compatible with palm pilots). Simply store your own list of top used codes and the chief complaints list that is individual to your practice for easy access. Your medical billing partner can consult and create a special listing for you.

By raising your staff’s awareness to the importance of point of care documentation, you will greatly reduce your missed and simply lost charges and the prize is a larger revenue flow for your practice!

View all Articles by: Melissa Clark, CCS-P