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4 tips on documentation for accurate coding from Apache Health's president

Sean McSweeney, founder and president of Apache Health, a Los-Angeles based medical billing company, gave four insightful tips on documentation for accurate coding:

1. Detailed reporting of procedures performed in an itemized fashion, as well as a description of the itemized procedures in the body of the report, is a must.

2. Detailed reporting would include the sizes and lengths of a mass or lesion, and detailing excision versus debridement.

3. Document complexity by writing a paragraph solely dedicated to explaining the complexity of the procedure to increase procedural services (modifier 22).

4. The medical necessity for a co-surgeon or an assistant (AS, 80, 62) is becoming more important in today’s climate.

More articles on coding, billing and collections:
Grab a pen – The key to successful billing and coding is documentation
Dr. Salomon Melgen gets 17 years for stealing at defrauding Medicare at least $73M: 5 insights
Iowa physician's license to practice indefinitely suspended for providing inappropriate pain management: 6 things to know

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