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Medical Documentation Tips Post ICD-10 Implementation

December 22, 2015

documentation_and_billing_1-1.jpgThe healthcare industry is well aware of the new ICD-10 coding practices. And while many offices have endured numerous challenges adopting these new codes, many have also discovered when turning to the services of an ICD-10 adoption service provider, the adoption process itself becomes greatly simplified. In addition to these new coding practices, effective documentation must be maintained; however, this becomes quite difficult for many practices, especially those that provide multiple specialty services. Here’s a look at medical documentation and coding practices that all clinics can follow and seem to be especially beneficial to multi-specialty offices. 

Separate Specialties According to Certain Days or Time Periods

When you have physicians who practice in various specialties, it is imperative that they keep the specialties separated as much as possible in terms of seeing the patients; this will augment improved documentation and coding practices. For example, if a practice offers SLP, PT and OT services, then providing all OT services two days a week, all PT two other days a week, and SLP two other days a week — or however your practice needs to provide them — will greatly simplify both workflow and documentation issues. You can also follow this tip by keeping specialties separated according to certain time frames — SLP before noon, PT from noon to 3:00, and OT from 3:00 to 5:00 or however it works best for your clinic. 

Proper Training and Education is Key

In a report recently released by The American College of Physicians, the author says “that practices should define guidelines based on consensus-driven professional standards unique to individual specialities.” This includes the ability for physicians to prioritize the needs of the readers. Physicians need to differentiate their coding and documentation practices according to who the information will be sent to; this not only enhances the communication process of documentation and coding, but it improves workflow.

Tips for Maximizing Your Medical Practice’s Return On Investment

It’s also pertinent that all applicable staff members have access to ongoing documentation education. In today’s healthcare industry that is affected by technological advancements and discoveries on a daily basis, medical staff need to be trained on how to accommodate these advancements with the documentation and coding that they provide.  Ideally, this education will be provided each time an update occurs to the electronic health record software being used. It may range from 5-minute training to 5 days of education. Just remember, the more specialties that a clinic has, the more education that will be needed to keep up with today’s best coding and documentation practices. 

Customize Objective Tests

When patients enter into a multi-specialty clinic, this is often because they will require multiple types of services being offered by various physicians. The initial evaluations that are carried out with each physician can be timely, and when not approached correctly, the documentation of the visit can become extremely long and clouded with questions. With customized objective tests, though, it becomes possible to create individualized evaluation templates, which allows physicians to document a shorter, more accurate objective section, which results in an increase in both efficiency and consistency, and this ultimately leads to better patient care. 

If you operate a multi-specialty clinic, it is imperative that you be up-to-date with today’s latest ICD-10 coding practices, and along with the adoption of these new guidelines comes the need for improved documentation. With M-Scribe, you can make the switch and enhance your documentation all at the same time, which allows you to better serve your patients with the proper services. 


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