Documentation and Coding

   You know what you did.
   We know the guidelines.

Evaluation & Management
We will provide you with the HCFA/CMS documentation guidelines and show you how to incorporate those guidelines into your documentation and coding. As the guidelines can be quite tedious we can also educate you on the use of a PDA program that assists in easily identifying the correct code based on an algorithm that meets the HCFA/CMS guidelines.

Diagnosis
We will educate you and your staff on the complexities and importance of proper diagnosis coding. According to a survey taken by the Health Insurance Association of America 43% of overall fraud activity was for fraudulent diagnoses.

Procedural
We will educate you and your staff on the nuances of procedural coding including bundled services and correct modifier usage.

Proper documentation and coding has multiple benefits. It can
increase revenue while decreasing compliance risk.

Charges Captured

There are three important pieces to charge capture:

   Capture- Is there a system in place that assures claims are submitted for all rendered services?
   Accuracy - Additions, deletions, and updates to CPT, ICD-9 and HCPCs occur on an annual basis. Has your current charge capture method been reviewed since the last code changes were published?
   Timeliness - How long does it take your charge from the time services are rendered to the time they are billed and can that timeline be shortened?

We will assist in revising your current superbill or work with you to identify an electronic charge capture system that best fits your needs and encompasses the three pieces identified above.