We have identified five of the most common areas where documentation can be improved.

Documentation of procedural steps and outcomes is key to proper reimbursement. The absence of specific information that is required for certain procedure codes will result in downcoding and unnecessary underpayment. Charge capture and coding is a
shared responsibility, but many physicians don’t receive feedback about deficiencies in their documentation. Without this, an error or oversight can be repeated until it becomes routine and the result becomes more costly to the practice.

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