Making sure that the reimbursement and coding reach optimum levels is crucial. It is vital for the healthcare professional to be careful during the process of documentation. All the entries in the records of medication are required to be legible. Documents that are not legible can be wrongly read and this can lead to medication faults. This is required to be done by adopting a standard which is legible within its compliance program. Another crucial thing to be checked on during the billing and coding process is that the healthcare professionals who treats the patient are needed to order all the diagnostic tests land sign. This, therefore, means that if any test ordered by the nurse who treat certain patent is not reasonable. It is, therefore, important to create a template for the most commonly ordered tests for diagnosis. The template of ordering tests should, however, be authenticated with the ordering nurse signature.
Furthermore, it is crucial for the healthcare professional to record the patient’s HIP. The 3 major E/M service elements are the patient’s medical decision, examination, and history. The history of the patient is typically composed of the client’s complaint, PFSH, ROS, and HPI. All the appropriate essential elements of the patient status should be considered. Diagnosis is required to always be coded and documented to the chief diagnostic specificity for the services that have been offered to this specific patient. The documentation in the medication record is required to support the ICD-9-CM and CPT codes reported on the health insurance claim form. Also, another crucial aspect to be checked on is that one is not supposed to code diagnoses terms that indicate ambiguity. Healthcare provider is needed to code all the conditions that are documented coexist at the period of visit
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