We all know the phrase “If it’s not documented, it didn’t happen.” The question is, “how do you document what happened, accurately, in a confusing EHR, in a way that will meet requirements and allow you to get paid?” Not an easy thing to answer but there are a number of tools and resources for providers and administrators to help. Tools range from the EHR to the billing team (internal/external), and utilizing external resources. Administrators must help their providers be knowledgeable of the tools available and the guidelines required.
Accurate documentation is a key to appropriate coding and charge entry which are major parts of the revenue cycle. Administrators should assure that their providers know how to accurately document what happens in their encounters with patients. Today this revolves around a provider’s use of the EHR, as 85% of office-based providers use one. Providers should not be focused on insurance/payer requirements. This is the prerogative of the billing department. Instead, knowing and following coding and documentation guidelines should be the priority. This requires constant training and communication between a clinic’s billing team (internal or external) and providers.