Documentation in Homecare Coding

Posted on Tuesday, May 23, 2017 2:06 PM

With ICD-10, came the requirement for more specific documentation to go along with all the new, specific terms and codes. Home health seems to struggle with this requirement since we code before the services are rendered, unlike many other medical fields, complete and confirmed documentation can be difficult to obtain in some instances. There are a few things agencies can do to help meet these requirements:

• Verify all diagnoses with a physician. This will address many of the issues concerning unspecified codes, unverified diagnoses or gaps in information. Many agencies are missing out due to the lack of proper documentation/verification.
• Keep communication lines open with your coding department/agency. This is a crucial part of the process. Better communication will lead to better documentation which will result in a higher quality of coding/review.
• Document, document, document! Remember, if it’s not documented, it didn’t happen.

Be consistent! Standard procedures in place can lead to fewer errors/audits and better outcomes.

Written by Mary Deakle, BCHH-C, COS-C, Corridor’s Manager of Compliance and Education.

About Corridor

Corridor is the nation’s preferred partner and trusted business advisor to home health and hospice providers, providing quality services and impactful results for 30 years. Focusing on key operational, regulatory and financial challenges, Corridor delivering industry-unique solutions and deep expertise in coding, clinical documentation review, compliance, billing and collections , consulting and provider staff education . At Corridor, we make the business of caring for people Better! For the most important industry updates and news that impacts home health and hospice, please make sure to sign up for our weekly newsletter to receive the latest up-to-date industry information direct to your inbox!

For additional information, please contact Corridor at 1-866-263-3795.

Go Back

Explore Corridor’s Solutions

Share This Story, Choose Your Platform!