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Physician Documentation and Coding Can Have Significant Provider Impact

Posted by David Fong on Nov 27, 2019 2:55:00 PM


A recent Forbes article entitled “Physician Documentation And Coding: The Third Rail? showcased the potential missed opportunities to fully understanding the correlation between physician documentation and coding and their resulting effects. Whereas patients may interpret documentation as a doctor providing an account of your visit in your medical record, providers have a far greater impact with documentation. Documentation and coding can affect revenue, quality of care, and potentially expose providers to legal compliance consequences.


Poorly managed coding directly affects revenue. Applying the wrong codes to the wrong situations often results in missed revenue opportunities or unjustified revenue. How does this come about? Lack of quality training and overall disinterest in the minutiae of coding are two reasons. Many providers are often more interested in seeing patients than the tedious work of proper coding, so it’s understandable that training may not a priority. And when coding is an afterthought, practices may experience reduced quality of care and exposure to possible legal ramifications. On the broader scale, coding errors are costly. In FY 2018 alone there was an estimated $31.6 billion in loss to Medicare attributed to preventable (non-fraud) errors.


In contrast, good documentation provides accurate documentation of care and good quality of care, as well as protects doctors and other medical practitioners from the legal risk that attends from incorrect coding and billing.


The article highlights that medical practices and health systems can help ensure high-quality coding and documentation—and therefore more accurate reimbursement and better quality of care—by these four steps:


  • Ensuring that visits are properly documented and coded by providing education that includes refresher training at periodic intervals (e.g., annual training on standards, changes in codes, etc.)
  • When a clinician has had significant errors, ensuring proper remedial follow-up for the clinician with a goal of improving coding accuracy
  • Ensuring that, even when doctors pass coding audits, their work is still assessed in terms of volume coding within given time frames, places of service (e.g., surgery versus clinic time), etc.
  • Rinsing and repeating….often


Aviacode provides experienced medical coding solutions, which can help practitioners to understand the deeper implications of their coding processes and documentation practices. Our team helps practices by ensuring coding is managed accurately and reflects all the latest regulations and requirements. We shed light on accurate coding’s multiple interconnections to a practice’s overall success. Our certified AHIMA or AAPC coders accurately code more than 10 million encounters per year, helping providers avoid costly mistakes and improve their revenue integrity. From the patient perspective, the documentation of their visit seems straightforward. They come in for a checkup, the nurse and doctor take notes, perform some exams, and that’s it. But on the back-end of the patient interaction there’s a complex coding and billing process for practitioners, a process that is frequently overlooked by physicians and staff.



Topics: ICD-10, Medical Coding, Coding Compliance, Pro-Fee Coding, Facility Coding