Clinical documentation is one of the most essential parts of a patient visit, especially in today’s world of electronic health records and medical billing systems that integrate directly into the EHR to bill for services. When documentation is accurate and complete, claims can be submitted immediately and patient billing moves forward seamlessly. When it’s not done correctly, it can lead to denied or rejected claims, delays in payment, and even more serious consequences for incorrect coding (upcoding or undercoding, both of which are fraudulent).
At the same time, documentation is frustrating and time-consuming for many providers—even CMS recognizes that they are placing too much of a burden on providers with all the current requirements. The compulsory information for Medicare and other payers can be overwhelming, and it differs from one to another so it’s easy to get confused about when you have to include what information, and how much of it is required for a claim. Many clinics have started using templates in their EHRs to make it easier, but those often require some customization to capture information unique to each individual patient.
Why Documentation Errors Matter
Errors in clinical documentation are one of the most common reasons that a claim gets rejected by a payer. When that happens, it creates more work for your medical billing staff because the clock is ticking on correcting and resubmitting the claim. Failing to get an appeal sent within a specific timeframe means the insurance will not pay, and you are left with the choice to either bill the patient for the full amount (which would be frustrating for a patient when it was your error that caused the claim denial) or to write off the unpaid amount as bad debt. Neither are ideal for your revenue cycle or cash flow.
Most of the time documentation errors are simply information that is incorrect or incomplete on a patient’s chart, for example, missing information about a treatment plan or failing to put the specific diagnosis.
How to Improve Clinical Documentation and Claims Payment
With as many different things expected of providers, it can be difficult to keep up with documentation, especially if you are not fast at typing. One of the easiest ways to submit complete and error-free documentation is to use a speech recognition solution to dictate your notes, so they are automatically transferred to the patient’s chart.
We partner with AdvancedMD to offer the most powerful speech recognition solution available, Dragon Medical One, which is fully integrated with other tools to make your documentation seamless and simple as part of your practice management software. You can use Dragon Medical One on a desktop computer with an attached microphone, or on any portable device (laptop, tablet). The PowerMic Mobile app allows your cell phone to serve as a microphone, giving you extra mobility while seeing patients. Dragon Medical One is secure, HIPAA compliant, easy to use and cloud-based so you can enter information from any device, at virtually any location.
Sales@1st-dragon.com | 866-977-3324 or 877-272-8280