Residency

Tip of the week: Accurately document for coding and billing

Residency Program Insider, August 28, 2007

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When dealing with coding, billing, and reimbursement, residents should document when care is provided, and understand that history & physicals, operative reports, diagnostic tests, and treatment orders are critical for accurate coding.

 

Residents should document the patient's severity of illness and his or her clinical rationale for ordering the intensity and level of care he or she is prescribing. He or she should also be open to suggestions regarding appropriate language for documentation made by case managers and coders in your facility.



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