2023 Gastroenterology Reimbursement and Coding Update (Virtual) | 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 the video, the speaker discusses various documentation errors in gastroenterology and provides tips on how to avoid them. They emphasize the importance of ensuring that documentation supports the level of service being billed. The speaker advises against cloning, inappropriate template use, and contradictions in documentation. They explain that diagnosis coding is crucial and that multiple diagnosis codes should be used to support higher-level visits. The video also covers the significance of chief complaint and HPI consistency between different staff members involved in patient encounters. The speaker stresses the importance of accurate and detailed documentation, avoiding vague terms, and focusing on impression and plan of care. They provide specific documentation tips for reason for visit, hospital follow-up visits, consultations, and history review. The video also touches on concurrent care issues, cloning errors, and the safe use of templates. The speaker concludes by reminding healthcare providers to train their voice recognition systems, complete any rejected dictation notes, and ensure that documentation is clear and accurate to avoid denials and recoupment of payments.

Asset Subtitle

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

Keywords

gastroenterology

documentation errors

diagnosis coding

accurate documentation

voice recognition systems