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Basic Rules to Follow for Outsourced Coding Without Losing Quality

Posted on Thursday, March 30, 2017 3:45 PM

Many in our industry believe that outsourced coding is not as accurate as coding that is completed in house. This is simply not true. Coding is only as good as your documentation. You can outsource and still have high quality coding and reviews by following a few basic rules.

Include or offer access to all necessary documentation: For example, the current OASIS, current medication list, referral information and any available H&P’s or discharge summaries. Coders require additional information such as: Laterality (which side is affected by the disease process) or specific severities of non-pressure ulcers (limited to skin, fat layer, muscle or bone necrosis). Having access to this information can greatly improve the quality of your coding and OASIS reviews.

Verify all diagnoses with the physician: Before you send your charts off to coding, verify any conditions that have been reported by the patient or family member with the physician. Homecare codes before any care is provided, therefore we should be creating the most specific plan of care possible to plan ahead for any unexpected issues.

Provide clear documentation of what care is being provided by your agency: Be sure to include goals, interventions and what disciplines will be providing care to the client. A great clinical summary can be very effective in painting a clear picture of your patient’s road to recovery.

The largest errors I have seen are based on a lack of proper documentation. We need the same information that you would use if you were coding in house. The more documentation we receive, the higher quality of coding we can provide.

Written by Mary Deakle, BCHH-C, COS-C, Corridor’s Manager of Compliance and Education.

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