The Importance of Proper Documentation by Gastroenterologist and Reimbursement Policies

Make no mistake, the proper documentation of a patient’s medical records has always been a priority, but it has never been as important as it is today, especially because reimbursements are often tied to a quality medical record. In short, the medical reimbursements provided by the government or insurance companies are reflective of what is documented, even more so than the medical procedure that’s been carried out.

Here, we are going to take a look at why it is so documentation by gastroenterologists, as per reimbursement policies is so important, and the benefits.

Encourages Better Communication

Proper communication plays a big role in helping the patient get the right treatment. It is also crucial for the medical billing process. The what, why, and how of clinical care given to patients can only be communicated via the right documentation. If needed, other physicians can use the data to learn more about the patient’s history and continue to offer the best possible care. Since proper documentation as per HIPAA compliance is mandatory and encourages better communication and smoothens the billing process, it comes highly recommended for gastroenterologists. Luckily, there are professionals who offer this service and ensure you have the right documentation that follows HIPAA compliance. This is one of the reasons why many gastroenterologists outsource to medical billing experts. So, if you are a professional gastroenterologist who is not aware of the business side of medicine, it’s time you called in those who do.

Endoscopy Billing Procedure

In order to file charges for what was done, all medical procedures must be documented. This is mainly because, when treating the gastrointestinal system, gastroenterologists frequently employ a combination of methods. This means the proper documentation of the location of lesions/abnormalities, the manner of treatment/removal, and the reason(s)/indication(s) for such operations must all be documented. Different tools may be utilized, such as a biopsy or a snare in the sigmoid colon. These services can be recorded individually with a modifier as an indicator that these procedures were carried out on various lesions/abnormalities.

Eliminates Risk Management Exposure

It goes without saying that documentation that is thorough, accurate, and follows HIPAA compliance decreases the chances of the dreaded malpractice lawsuit. In the case of a lawsuit, a well-documented record can serve as proof of treatment and care, reducing liability issues, and can save the gastroenterologist’s practice. Proper documentation is especially important if the lawsuit has been brought against you after several years. When you are in the middle of a professional liability lawsuit several years later, it is doubtful that you would recall details of a specific instance. In this case, your documentation will be your go-to resource.

Medical Diagnostics

In order to submit charges for diagnostic investigations, the medical necessity/indication for the testing must be established. The words “rule out” and “suspect” don’t provide coders with a comprehensive picture of why a physician believes a patient has a disease. Atypical lab tests, signs, and symptoms almost always indicate the need for additional inquiry, and these are the most important reasons to test. This is critical not just for diagnostic tests but also for treatments. Ascertain that the interpretation of the test results, as well as a plan/recommendation, are both clear.

Ensures Proper Reimbursement

It goes without saying that well-documented medical records may help with successful revenue cycle procedures, accelerate payment, eliminate claim processing “hassles,” and assure proper compensation. Good documentation procedures, which most of our physicians are familiar with, account for 95% of assuring adequate compensation. The remaining 5% consists of studying the regulations supplied by the federal government and other organizations that we need to know in order to be compensated appropriately in terms of paperwork compliance.

Assignment of Diagnostic Codes

Any type of service provided by a gastroenterologist can have up to 12 diagnostic codes assigned to it. This also includes preauthorization of all services, including lab tests, radiological studies, GI diagnostic investigations, and surgeries, which is also required. This is crucial, especially since insurance providers tend to refuse certain lab and radiological investigations and some treatments if particular information is not available or has been left out in the documentation.

Reviewing and Reference

And finally, the right documentation management can also allow gastroenterologists to review prior records for reference while providing current EMRs. The good news is, some health records even allow gastroenterologists to view previous records from other medical facilities as well for reference or collaboration. This can only be made possible if the right documentation procedures are followed under HIPAA compliance. This is where third-party service providers can come in handy. Nobody knows the ins and outs of managing gastroenterologist’s practice documentation than professional medical billing and revenue cycle management service providers.

It is crucial for gastroenterologists and other gastroenterologist-related fields to understand the importance of maintaining proper and accurate patient documentation to mitigate the risk of malpractice and getting reimbursements.

JBF Medical Billing, LLC. is an experienced and reliable billing service exclusively for gastroenterologists and gastroenterologist-related practices. What makes this service unique is that we offer it specifically for gastroenterologists and gastroenterologist-related practices. This means that your medical billing is being taken care of by the experts. Our medical billing software links easily to most of the EHR (electronic health records) software that physicians use.

JBF Medical Billing LLC. is also a proud member of the American Gastroenterological Association (AGA), the American Association of Healthcare Administrative Management (AAHAM), and the American Medical Billing Association (AMBA), so you can rest assured all of your Revenue Cycle Management and HIPAA Compliance are taken care of by the experts.