Clinical Documentation Tips to Survive RAC Audits and Maximize Reimbursement

Physician practices are under pressure to implement the electronic medical record system by next year. This is posing serious challenges in the documentation of medical records. Improper documentation affects health care quality. Moreover, accurate documentation or medical transcription is the key to surviving RAC audits and preventing reimbursement loss. Here are some important considerations when it comes to ensuring high quality clinical documentation:

• Being timely has a lot to do with quality in patient records. History and physical notes and operative notes need to be signed within 24 hours of the patient visit and medical records, within one week after discharge. Time-based codes require accurate documentation of time.

• Documentation should be made clear and comprehensive, and include all the relevant details. Only an information-rich record allows proper reimbursement and improved patient care.

• Blindly following shortcuts and pick-lists of new digital record is not advisable as it might lead to restricted documentation. 
  

• Expanding SOAP notes would be a good idea and adding additional details in the columns available would help in effectively using the record for future care and for better filing of claims.

• Documenting details without delay at the patient encounter would ensure that important details are not missed out, and is rated a best practice.

• State procedure specifics. In the case of surgical notes, it’s important to specify the approach, all the procedures performed, and any unusual incidents that took place during the surgery. For instance, when it comes to lesion measurements, it is necessary to specify when the measurement was taken and if the measurement is inclusive of the margins. Only this can ensure accuracy in coding.

• In order to avoid health care complications and to be free of unwanted legal issues, it is advisable to perform timely verification of the entered data. Always check for possible errors that might encounter in the records and be sure that they are cleared promptly.

• In addition to verifications, performing internal audits regularly would assure top quality for patient records. Before signing the notes, it is crucial for physicians to take responsibility for the accuracy level.

• Make use of professional medical transcription services. The need of the hour is clinical documentation that is extensive and detailed. Only a team of skilled and trained personnel can handle the complex documentation tasks of your healthcare practice.

To be confident about accurate health documents which pave the way for overall efficiency, proper reimbursement, and survival of RAC audits, busy physicians can rely on a professional medical transcription company. Adhering to best practices in managing health records is sure to boost reimbursement and practice revenue.