Sally Streiber, Director of Provider Compliance, University Hospitals. Erica Remer, President, Erica Remer, MD, Inc..
April 8, 2019
Documentation doesn’t have to be difficult or lengthy; it must be accurate, relevant, complete, and specific
Optimal documentation supporting maximally specific diagnosis codes results in improved demonstration of medical necessity, ICD-10 and CPT coding, quality metrics, and reimbursement
Ongoing provider education and formative feedback is essential for improving clinical documentation, specific diagnosis code choice, and appropriate evaluation and management level selection
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