Improvement

Getting Paid

Assertive Documentation Justifies Highest Level Coding

Attention to detail has never been more important for recording and reporting physician services. With financial pressures from payers, insurance carriers, and others, a special effort is necessary to ensure that all services are billed and documented properly. A clear and deliberate focus on maximizing revenue is necessary to yield a financially healthy practice.

It is now clear that documentation is primarily a billing record. Time spent improving and refining documentation is typically rewarded with higher reimbursement. Documentation must be assertive, that is, it must clearly demonstrate the requirements for service codes. When you are armed with assertive documentation, you can confidently maximize billed services. In fact, many physicians find that improved documentation leads naturally to higher reimbursement of the same services that were previously billed with fewer or lower level codes.