You may not receive the maximum third-party reimbursement if your records are indecipherable or incomplete. Bad handwriting and poor-quality photocopies can lead to missed information, poor coordination of care and even duplication of procedures and tests. External reviewers may dispute utilization rates that are unnecessarily high. Chart notes dictated immediately after a patient visit, transcribed, reviewed, signed and dated that day can eliminate this problem. Inadequate documentation is another trouble source.
Most physicians use negative charting, noting what is abnormal or unusual.
This system can lead to lower reimbursement by failing to capture all services provided or to cross-reference them with fees billed. The acronym stands for Subjective findings, Objective findings, Assessment and Plan of action. If these items are not present in your progress notes, your files are deficient. With Medicare and with an increasing number of private carriers the higher the code billed, the more documentation is required. Most physicians wish to save money on malpractice insurance premiums, which consume a significant part of practice overhead.