Practical Documentation: 3 coding and documentation mistakes to avoid

Published: 2009-08-03 00:11:32
Author: Kathy Mills Chang | Chiropractic Economic | October, 2008

You want what every doctor wants ó an office that runs smoothly, high satisfaction for all employees, systems and procedures in place, no compliancy issues, and financial rewards for all your hard work.

But letís face it; coding is the language of reimbursement. You have certain numbers to describe your work and your patientsí conditions. If you donít know every nuance of using these numbers, it can cost you thousands of dollars.

The following are three of the biggest coding and documentation mistakes that, when avoided, allow for smooth sailing.


Evaluation and management (E/M) codes are one of the most important sets in your coding arsenal. You must strive to get it right and document thoroughly since codes set the tone for the care you will render to your patients.

 Periodic re-evaluations carry significant weight to justify medical necessity for ongoing care. However, E/M codes are also one of the sets that are under and over coded most often. Lack of understanding among practitioners of the requirements for new and established patient E/M codes is often the problem.

The Centers for Medicare and Medicaid Services (CMS) has set forth clear guidelines for whatís required for documentation of these services. Because many doctors have never seen these guidelines, they tend to use whatever code feels right, or rely on the amount of time spent.

Because of this, some doctors are actually either too high or too low for the amount of work performed. Itís likely that when you review your information, and make a checklist of the items required, you will be surprised at how much work youíre doing that youíre not charging for. Or, it may indicate that youíre not documenting completely.


Far too often, doctors code services incorrectly. One challenge comes from taking coding advice from inappropriate sources, such as from manufacturers of products without written references.

Doctors often rely on the fact that they may know what they did to the patient and feel justified in coding the service, but the documentation in the record doesnít correlate. Remember that ďwhat isnít written down, never happened,Ē so you must ensure all the services rendered are properly documented according to reasonable and standard guidelines.

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