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Coding tip of the day: Find key information in physician notes

The patient's chart contains important information for verifying medical necessity, said Jon Elion, MD, founder, president and CEO of Chartwise Medical Systems.

Dr. Elion shared the following tip with Becker's ASC Review.

"The long list of details required for proper chart documentation to support coding in the ASC environment may often overshadow a simple yet significant challenge.

Specifically, documentation in the ASC must stand on its own and contain all the information needed to document medical necessity and inform medical decision-making. This information typically starts and resides in the patient's chart in the physician's office, putting the onus on the ASC to check this physician documentation ahead of time to ensure required information from office notes is included in the ASC chart."

If you would like to share a coding & billing tip to be featured in our "tip of the day" series, please email Angie Stewart at astewart@beckershealthcare.com.

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