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Medical Billing, Coding and Documentation Services

Medical Documentation Service will be More Relevant in ICD-10 World

Posted by Alec Winfrey on Fri, Jan 18, 2013

Medical Documentation and ICD-10

Time and motion studies have been a part of business process engineering since the building of the great pyramids. The modernization of the industrial world depended upon using resources in the most appropriate and efficient manner possible. So how does building a Model T have anything to do with healthcare documentation and the creation of the electronic medical record. Simply put, healthcare documentation is a business process that takes raw material (voice & data) and creates a medical record. Outside of the course of treatment and as necessary and valuable tool in patient treatment, that record then must be coded, submitted, billed and ultimately collected. That’s quite a process. Health documentation is not that different from the assembly line, raw material is formed and processed, and at the end you get compensated for your effort.  

Today’s healthcare providers need all the support they get to make sure they are working as effectively as possible. Healthcare providers facing decreased reimbursement rates have needed to increased patient loads under the constant pressure to maintain revenue. The amount of information physicians must dictate or capture in their Electronic Health Record (EHR) in less time, is also growing. Obviously, additional patients have resulted in additional work for all of the office staff. Identifying time for in house staff to document dictations, file claims and track reimbursements along with their regular responsibilities isn’t realistic.  Attempting to do so can result in mistakes leading to compromised patient care and inconsistencies in documenting HIPAA compliance.

In the era of managed care, health care providers have discovered the benefits of hiring a reliable and complaint documentation service go way beyond just cutting costs. The need for providers today, is to be able to spend more time with patients and less time with non-patient functions. Clearly the benefits to outsourcing can help in today’s healthcare environment.

The transition to ICD-10-CM is a requirement that all providers must be prepared for. The investment for in-house services in the form of training will be another burden in both time and expense. The expansion of Codes from the current ICD-9 to ICD-10 is significant. The current ICD-9 system includes 17,000 codes to describe medical conditions, external causes of morbidity, factors influencing health status, and inpatient medical procedures.  ICD-10-CM contains 68,000 codes, not including the codes in ICD-10-PCS which describe procedures. This expansion in the availability of possible codes will require attentive review of available documentation in order to submit clean claims for timely reimbursement. Your best options for making this transition may be to look for a qualified outsourcing service that can provide all of the services to keep you up to date and compliant.

In the era of managed care, health care providers have discovered the benefits of hiring a reliable and complaint documentation service go way beyond just cutting costs. The need for providers today, is to be able to spend more time with patients and less time with non-patient functions. Clearly the benefits to outsourcing can help in today’s healthcare environment.

The Benefits of outsourcing a medical documentation Service:

  • ICD-10 implementation – with the transition to ICD-10-CM, some documentation issues will require providers to capture new information; others involve updated, modified and otherwise expanded documentation needs. To know more about it please visit www.m-scribe.com/Medical Documentation and ICD-10
  • Decreased cost – up to date knowledge and skills on what’s required to produce quality medical records which leads to quicker and less expensive services
  • Expertise – familiarity with a wide range of specialties provides mixed practices with professionals who can provide accurate documentation across numerous branches of healthcare
  • High Quality Records – regular employee evaluation with imposed penalties based on zero tolerance policy; careful editing and proofing of each document; full review of the complete record prior to delivery.
  • Decreased Investment – no need to buy expensive software and equipment necessary for proper dictation and medical documentation
  • Quicker Turnaround – extensively trained specialists ensure a fast turnaround
  • Compliant with Regulations – demonstrated compliance with HIPAA regulations
  • Encryption Upgrades – state of the art encryption programs ensure secure transfer of patient information

Please ensure that any medical documentation that you hire only employs personnel with documented experience and exceptional skills to perform a variety of tasks. They should also provide service in a timely manner with customized formatting for your business and that all employees are HIPAA compliant. Paying attention to these factors will help you hire a team who will provide the best service possible for your practice.  

Remember the true secret for improved reimbursements and accurate coding are rooted in proper medical documentation. Complete documentation submitted in a timely manner, it’s really no secret.

Tags: ICD-10, Medical Coding, Medical Documentation

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