Documentation Review

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Documentation Review

Once encounter is locked; coding team retrieve a random sample of weekly notes and review of components of SOAP notes/encounter to ensure proper guidelines are followed and support the coding chosen on the superbill. Education is provided to doctors on their usage of CPTs/ICD-10s.

How do we do it?

Once the visit note is locked, coding team retrieves a random sample of weekly visit notes and review the components of the documentation to ensure proper guidelines are followed. Education is then provided to doctors on their usage of CPT/ICD-10 to help them improve on future documentation.

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