Read the case study about the University Clinic Associates Below:
University Clinic Associates employs over 200 physicians who are on the faculty at the University Hospitals and Clinics. With 20 specialty clinics and over 2000 clinic visits a week, accurate coding and documentation of these encounters is critical to obtaining the correct reimbursement. At present, each clinic is staffed with mostly clerical staff members who do the scheduling of appointments, registration of patients, and data entry from encounter forms for billing purposes.
To assess the current situation, William Murken, the financial manager responsible for the clinics, has hired you (an RHIT with a CCS credential) as a consultant to conduct a coding and documentation audit.
You meet with the staff to go over the records and complete the audit. After you have established a rapport, you remind staff members that accurate diagnostic and procedural coding cannot be achieved without clear and complete health record documentation. There are many instances where documentation omissions, such as the specifics of a service, can affect reimbursement.
Nowhere is this truer, you explain, than in recording Evaluation and Management Services. Virtually every physician performs E/M services. Thus, the impact of coding and documentation on the reimbursement of these services is enormous. When billed services cannot be substantiated using documentation in the health record, the physician may not get paid or may have to refund over-payment.
The staff seems to appreciate your input. One person comments, “This will give us a target as we assign medical codes in the future.”