Kenyon HomeCare ConsultingValuable Documentation And Coding Advice To Start The New Year Right - Kenyon HomeCare Consulting (206) 721-5091

Kenyon Connects

Valuable Documentation And Coding Advice To Start The New Year Right

Starting the new year right mean various things to different people. But to homecare owners and managers, eliminating nagging coding problems and increasing the bottom line ranks high on their list of 2017 wishes. The best way to gain better coding practice benefits, is by backing up your coders with a full-fledged, fundamentally sound, documentation strategy. This approach enables your agency to receive maximum reimbursements every day of the year.

Below, we offer five pieces of sound documentation and ICD coding advice that can easily translate into your home health agency’s new year resolutions:

A Home Health Documentation Plan for 2017Documentation

1. Train and retrain clinicians for optimal documentation

In order for your ICD coding to be 100% accurate and complete, the clinical documentation must be 100%. Given the complexity of ICD-10 and the greater diagnoses specificity requirements, you cannot afford poor documentation. Investing in ongoing documentation training will keep clinicians up to date and help form proper documentation habits.

2. Keep constantly up to date on all coding changes

Annual ICD-10 updates and periodic changes will affect your coder’s ability to secure maximized reimbursements. Keeping up to date and quickly implementing new changes is imperative. Don’t forget to also inform and educate your clinicians on new requirements to avoid delays and needless rework.

3. Be consistent. Your documentation must match that of other providers.

It is imperative to your bottom line and cash flow that your own documentation submitted to CMS be consistent with that of physicians, hospitals, and other providers. Both diagnosis and severity must match and there can’t be any differences in the coding sequence. In fact, it is best practice to communicate often with the physician in advance of claim submission to ensure full documentation alignment. Many agencies routinely forward copies of the OASIS, plan of care, and recertifications which become part of the physicians’ record.

4. Put a special focus on documenting recertification requests

Under ICD-10, even documenting routine visits like changing a catheter or filling a pill box must include goals and a duration end point. And documentation for every 14 day aide supervision visits must contain any changes, progress, or deviations from the current plan of care. But it is the 60-day recertifications that will likely present the greatest challenge. Specific, measurable goals must be clear and all progress toward meeting these goals must be explained in detail. Establish the need for continued care or risk losing out on reimbursements!

5. Document your progress toward coding/documentation success

From the beginning of the year to the end, you should monitor the efficiency of your coding and documentation efforts with monthly reports and coder/clinician feedback. By knowing where you’ve been, can you hope to move from where you are to where you want to be. Documenting your agency’s progress and knowing which staff requires retraining is an essential piece of your improvement plan.

The Importance of Winning the Documentation Battle

For your homecare agency to survive and thrive in today’s marketplace, getting optimal reimbursements for each client you care for is a non-negotiable. Medical coding is on the “front lines” of seeking full reimbursement from CMS, but battles are not won at the front line alone. Just as soldiers must have the correct ammunition to win the battle, coders must have accurate, complete, sufficiently specific clinical documentation.

When coders have to hunt up documentation that is missing, valuable time is lost. Worse, if CMS catches “red flags” in claims submissions, your agency payments may be denied or delayed. Clinical documentation that is complete, accurate and records progress toward goals is essential. This is never more crucial than when your Medicare Administrative Contractor (MAC) asks for additional documentation requests (ADR). Or when an onsite investigation results in fines or holds on reimbursement.

Valuable Documentation and Coding Advice Conclusion

As we head into 2017, every home health organization should work to improve coding and documentation efforts. This strategy will lead to greater reimbursements and a stronger bottom line!

To start your new year right, consider outsourcing your coding to the Kenyon HomeCare Consulting professionals. For help with coding, clinical documentation training on-site or via webinar, contact us today or call (206) 721-5091.

Category: ICD Coding

Leave a Reply

Your email address will not be published. Required fields are marked *