An important part of the medical visit process is documentation. This is the creation of a record detailing what happened during a patient’s visit, including issues or complaints, suggested medical treatment, required testing, etc. As such, you want to ensure that the documentation is clear and concise as this information guides the medical coding and billing for the services rendered.
As you can imagine, there are several reasons for documenting a patient’s visit properly. Here are a few:
- Communicating with other health professionals. Documentation is the what, why, and how of the care delivered to a patient. If these records are utilized by other providers or nursing staff, understanding the patient’s history is critical to providing the best possible healthcare.
- Reducing risk management exposure. An accurately documented patient record serves as proof of treatment and care, helping to lessen liability concerns in case of a legal claim.
- Ensures proper reimbursement. Correct documentation plays a vital role in revenue cycle management and ensuring that a provider is reimbursed appropriately for services rendered.
With your busy schedule, you may not have time to keep up with continuing education on how to improve provider documentation. This is why having Billed Right as a strategic partner can help. Our team has years of experience in reviewing documentation and providing feedback on utilizing proper coding and billing guidelines.
How do we do it?
We go into the documentation, only after the visit notes are locked:
- The coding team retrieves a random sample of weekly visit notes and reviews 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.
Documentation review is just one part of the Revenue Cycle Management process. Contact us today to learn more about how we can partner with you!
What clients say
Psychiatry Group, Ohio.
"I have been very happy with Billed Right and have seen a significant increase in collections since switching to them 8 months ago. They are professional, efficient, and respond to all my questions and concerns thoroughly and promptly. I highly recommend them and have referred them to my colleagues."
Internal Medicine Provider, Altamonte Springs, Florida
“As a practice entering commercial insurance for the first time, we briefly tried to manage our own billing before realizing that we really needed to bring in a professional. After interviewing several companies, we selected Billed Right who was committed to understanding our business model and become a true partner in our success. Over the past 18 months we have seen significant organizational growth and Billed Right has partnered with us to help facilitate that growth as they remain a key asset to our organization.“
Behavioral Health Provider, Connecticut
Account Managers are always readily available to help me. I appreciate their efforts daily! Our AM is a true gem and gift to any client account she manages. Her knowledge and suggestions aid me and my clinic in many ways. I would never have been able to execute a few items without her help. I was not in my current role before they chose to use Billed Right, however, I do see reports that show substantial increases in Revenue for my company. I appreciate the transparency of reporting, coding, and claims with the team and within the system. I would highly recommend Billed Right to others. In fact, at the most recent Meditab conference, Billed Right’s contact information was given freely with praise to several small business owners in need of financial assistance.
Practice Administrator of Urgent Care, TN
Billed Right has depth that similar service organizations do not. There is not a one or two-person team that handles everything. It is an organization that as a team understands our account. We have senior leadership, on the ground leadership and day to day team members that know our account. That is not easy to replace and certainly, at our size, not something we could bring internally without a significant commitment to infrastructure. While we cannot speak to how they may align with a specific set of needs…they are a professional organization with solid tools. Ultimately you will choose an outside billing partner for the simple reason of increasing collections. This will happen with Billed Right…but to us…as much as increasing our cash flow is their team of professionals. I like them, respect the contribution they make to our company and openly offer my personal recommendation.
CEO, Pain Management, CA
I have been associated with Billed Right for the past two years since I started my practice. Billed Right have been incredibly helpful in assisting my practice with initial credentialing, providing prompt responses to all my requests and excellent service to address my concerns. I am very satisfied with their timely insurance billing, collections, low AR, and patient accounts management. My Account Manager meets with me regularly to review and discuss management reports and address my questions in a professional and promptly manner. I am very satisfied and could not ask for better service. For these reasons I highly recommend Billed Right to anyone looking for a reliable practice management service.
Psychiatry Provider, FL
Billed Right is very knowledgeable in every aspect of business. When our Dr. First acquired the practice, it was a huge mess because one provider was leaving, and one was coming in but Billed Right stuck in there with patience and loyalty. Account Managers are top notch when it comes to every aspect of the business and make sure that you are comfortable in what they teach you. Staff members are very competent and have patience of saints to put up with credentialing and enrollment processes. Staff are polite and know what they are doing and go out of their way to help in every situation. I want to thank each one of the teams. Patient call rep is awesome and is also top notch in the field.