2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing | November 2021-Top Documentation Errors in GI: How to Avoid Cloning Issues, Inappropriate Template Use, and Contradictions

Top Documentation Errors in GI: How to Avoid Cloning Issues, Inappropriate Template Use, and Contradictions

Video Transcription

Video Summary

In this video, the speaker covers various topics related to medical documentation and coding. The speaker highlights the importance of accurate and specific documentation to support the level of service provided. They discuss concurrent care issues, where services are performed by multiple providers on the same patient, and emphasize the need to submit documentation to prove medical necessity if denied. The issue of cloning, copying, and template use is also addressed, with Medicare contractors stating that if notes look too similar, they will recoup payment. The speaker emphasizes the need for individualized patient notes and the importance of reviewing and customizing templates. They also touch on dictation and voice recognition, advising providers to train their voice recognition systems and review notes for errors before signing. The video includes various comments and recommendations from different Medicare contractors. The speaker concludes with a humorous comment about the challenges of reading doctors' handwriting in charts and the potential errors in EMR typing. No credits were provided.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

medical documentation

coding

concurrent care

medical necessity

cloning

voice recognition