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Why Clinical Documentation Is Important

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businesswoman-taking-notesAs you are grappling with the new ICD-10 coding system, you might often feel overwhelmed and wonder if documentation is a burden that isn’t even necessary.

But however overloaded you might feel, it’s important to remember that clinical documentation is the key to getting paid. Without proper, detailed documentation of clinical encounters, practices will not receive correct and timely reimbursement. And getting paid is the only way to keep your practice running and your patients cared for.

At the end of the day, good documentation and coding habits are beneficial to your working environment and to your patients; in fact, it has even demonstrated leading to an increase in reimbursement amounts.
It’s starting to sound like it’s worth the immediate headache, right?

The quantity and type of new concepts required for ICD-10 is actually nothing new to clinicians. The focus of clinical documentation is, and always has been, good patient care. Your patients deserve to have accurate and complete documentation of their conditions. The value of thorough data is something that all industries understand and give substantial priority to—physicians are no different.

On the flip side, poor-quality documentation is bad for everyone—payers, providers, and patients alike. Billing accuracy, quality measures, population management, risk management, and health-care analytics are all negatively impacted when a practice lets documentation slide. And, of course, if the operational functions of a practice are falling short, the patient care will also suffer.

Still need convincing? Here is a breakdown of the major reasons documentation is important.

7 Reasons We Need Clinical Documentation

  1. Accurately measures quality and efficiency
  2. Enables accountability and transparency
  3. Provides better business intelligence
  4. Supports clinical insight and research
  5. Underscores the level of risk and severity
  6. Enhances communication with hospital and other providers
  7. Ensures proper payment and reduced denials

But most important: It’s good patient care, pure and simple. That’s why we’re in this business, after all.

If you need help establishing a clinical documentation system for ICD-10, contact us today.

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