What is a "Documentation and Coding Assessment?"
In general, this refers to an outside, objective review of a practice's documentation and coding practices. Often (but not always) these assessments focus on Evaluation and Management (E&M), or visit, codes; this is because E&M coding is often a practice's biggest compliance risk area. For example, if a practice bills out large numbers of level 4 visits, yet its documentation supports only level 3 visits, this presents a legal and compliance issue. Our goal is to help practices avoid documentation and coding problems by identifying potential risk areas and educating physicians and staff about the federal requirements.
When MMRI provides a Documentation and Coding Assessment, we often assign both a practice management consultant and one or more coders to the project. We have found that our clients appreciate the input and direction of an experienced practice manager working together with a certified coder.
Typically, we review a number of charts per provider, then prepare a report summarizing each provider's documentation patterns and comparing the providers to regional and national utilization benchmarks.
What type of "Training" does an assessment include?
Following the chart review and the report preparation, our consultants meet with our clients to present the findings and provide training, using examples from the provider's documentation. Depending on the needs of the client, the presentation and training may be brief, or it may be more detailed, involving multiple visits to the provider's office. At the conclusion of the training, we provide a manual to each provider with documentation and coding resources.
Why should I have a Documentation and Coding Assessment and Training program for my group?
The Office of the Inspector General has targeted documentation and coding practices for intense scrutiny in the past several years. A professional documentation and coding review can reveal risk areas within your practice and give you the knowledge and tools to correct them. Many practices have come to regard their annual Documentation and Coding Assessment as an integral part of their compliance effort.
What are MMRI's fees for Documentation and Coding Assessment and Training?
Our fees are customized and depend on travel required, the number of providers in the group, the group's specialty, the number of charts we are asked to audit, and the type of training program the group requests. We would be happy to speak with you and provide you with a firm quote for your documentation and coding needs!
For more information, please contact our sales department at Sales@mmri-ny.com
