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Documentation in Homecare Coding

Posted on Tuesday, May 23, 2017 2:06 PM

With ICD-10, came the requirement for more specific documentation to go along with all the new, specific terms and codes. Home health seems to struggle with this requirement since we code before the services are rendered, unlike many other medical fields, complete and confirmed documentation can be difficult to obtain in some instances. There are a few things agencies can do to help meet these requirements:

• Verify all diagnoses with a physician. This will address many of the issues concerning unspecified codes, unverified diagnoses or gaps in information. Many agencies are missing out due to the lack of proper documentation/verification.
• Keep communication lines open with your coding department/agency. This is a crucial part of the process. Better communication will lead to better documentation which will result in a higher quality of coding/review.
• Document, document, document! Remember, if it’s not documented, it didn’t happen.

Be consistent! Standard procedures in place can lead to fewer errors/audits and better outcomes.

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

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