2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-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 discusses the top documentation errors in gastroenterology and provides tips on how to avoid them. They emphasize the importance of ensuring that your documentation supports the level of service that you bill. They discuss the significance of diagnosis coding and how it is crucial to paint a clear picture when submitting levels of service. They also highlight the issue of contradictions between the chief complaint and the history of present illness (HPI) entered by different staff members. Proper documentation of comorbidities, risk factors, and relevant details is recommended. The speaker advises against using vague terms and emphasizes the importance of providing specific and detailed information to support higher levels of service. They discuss concurrent care issues and how documentation should be customized and specific to each patient encounter. The topic of cloning is addressed, with various Medicare contractors stating their guidelines and definitions of cloning. The speaker emphasizes the importance of accurate and updated documentation, as well as the limitations and challenges associated with telehealth and voice recognition systems. The video concludes with a reminder to ensure that documentation is clear, complete, and supports medical necessity.

Asset Subtitle

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

Keywords

documentation errors

diagnosis coding

comorbidities

cloning

telehealth