Episode 381 - #Terry Tuesday - The Critical Importance of Documentation

The Compliance Guy

Summary

In this episode, Sean M Weiss and Terry Fletcher discuss various trends and issues in healthcare auditing, coding, and documentation. They reflect on their recent experiences and the importance of accurate coding practices to avoid risks associated with incomplete documentation. The conversation also touches on behavioral change interventions and the challenges providers face in maintaining compliance with evolving regulations. The episode concludes with a teaser for the next discussion on shared visits.

Takeaways

• Time flies, and boy, they were not kidding.
• An abundance of macros and smart phrases can lead to issues.
• Providers should only code for services actively managed during encounters.
• Incomplete documentation invites risk and potential legal issues.
• Behavioral change interventions require proper documentation and patient agreement.
• It's not the volume of documentation, but the quality that matters.
• Smart phrases and macros can lead to compliance problems if misused.
• The current administration is intensifying scrutiny on healthcare practices.
• Providers need to be aware of the risks associated with coding for unrelated diagnoses.
• Next episode will focus on the complexities of shared visits.