When a resident is involved in a service, the documentation provided by the TP is intended to supplement the more detailed documentation for the same service provided by the resident, and may be limited to brief, summary comments of the most relevant patient information which revise or confirm the resident's history, exam, and medical decision making. The combined entries must be adequate to substantiate the level of service required by the patient and the service code billed. This article emphasized that office-based physicians used to think that only hospitals had to worry about accurate codes for procedures on medical claims. That was before many physicians realized they were losing several thousand dollars a year through improper coding that either lowered reimbursement or forced the practice to re-submit claims. The present growth in the coding profession is from increasing awareness of compliance.
Physicians are concerned about fraud and abuse investigations.
With a professional coder, the physician's liability is lessened. Coders are willing to help physicians document and get reimbursed appropriately. The medical record is no longer a physician document but a legal audit document. This article emphasized that office-based physicians used to think that only hospitals had to worry about accurate codes for procedures on medical claims. That was before many physicians realized they were losing several thousand dollars a year through improper coding that either lowered reimbursement or forced the practice to re-submit claims.