Dr. Erica Remer clears up 3 documentation misconceptions

A lack of formal training contributes to providers' disenchantment with documentation, according to Erica Remer, MD, the director of an intensive medical documentation course at Cleveland-based Case Western Reserve University School of Medicine.

"As they progress in residency, they muddle through documenting of the patient encounter, guided by their superiors, who also have no formal education on documentation," Dr. Remer wrote in an article for ICD10 Monitor.

Here are three resulting misconceptions.

1. Documentation is an unnecessary burden.

Documentation is part of the service, not a superfluous task, Dr. Remer said. Requirements for evaluation and management levels of service can help uncover clinically significant and actionable information. Being explicit in medical decision-making helps substantiate medical necessity, enhance communication with other providers and improve patient care.

2. The more you document, the more you can bill for a level of service.

The E&M guidelines clearly state the volume of documentation shouldn't be used to determine which level of service to bill.

"When I am educating providers, I try to emphasize that the key is quality, not quantity, of documentation," Dr. Remer said.

3. Teaching advanced practice practitioners or residents is sufficient.

Providers should take steps to ensure high-quality documentation; they are accountable for any documentation done on their behalf, as well as quality metrics and technical and E&M billing derived from that documentation.

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