Coding and documentation requirements are an ongoing issue for physicians and other healthcare providers. Everyone, from government agencies like the Office of Inspector General to Medicare Intermediaries and insurance carriers, scrutinize physician documentation. Physicians and their staff need to be aware of the criteria and risks associated with current coding and documentation guidelines. Our healthcare consultants can take you through a medical chart audit to evaluate your documentation and assess your overall coding and billing practices.

A Comprehensive Chart Review

To ensure that your coding and billing complies with current rules and regulations, Schenck Health Service Solutions will review your medical records for the following:

• Appropriate ICD-9 and CPT Codes
• Applicable Modifiers
• Bundling Issues
• Missed Coding/Billing Opportunities
• Insufficient Documentation and Documentation Risk Factors
• Medicare and Medicaid Reimbursement
• Physician Utilization Profiles

We audit using both the 1995 and 1997 Physician Documentation Guidelines. You receive a report and individualized or group education based on your needs.

We offer a variety of options that you may select from to proceed with your chart audit. These options reflect different levels of educational needs for physicians and/or staff.

Education & Training

Schenck Health Service Solutions consultants can develop educational programs to meet your practice needs. Training sessions can involve physicians and/or office staff. Educational topics may include the following:

• Understanding Evaluation and Management Services
• 1995 and 1997 Documentation Guidelines
• General Principles of Chart Documentation
• Multi-Specialty Coding Topics
• Working with an Audit Tool

Ongoing Coding Resource

Schenck’s consultants are available as an ongoing coding resource for questions and concerns from you or your staff.  We remain updated on any changes in coding and documentation requirements as members of the:

• American Academy of Professional Coders
• American Health Information Management Association
• Wisconsin Health Information Management Association
• Wisconsin Nurses Association

Contact

To learn more about Schenck's coding solutions, contact Deb Pounder or Karen Holm.