Documentation & Coding

You can’t simply overwrite something, use White-Out, or scribble it out with a Sharpie to amend the record. When you need to change, add, or delete something from the documentation rendered at the time of service, you must follow specific guidelines.

In this informative video, KMC explains how to properly add treatments to a patient’s plan, even if they were initially overlooked.

One of the most common questions we get is whether regular re-evaluations are “required” for justifying ongoing, medically necessary care. Some say, “I heard that…

Don't miss out on this eye-opening discussion that could save your practice from regulatory scrutiny.

In an effort to have the best of both worlds, some offices are finding that using hybrid documentation allows their practice to stay compliant and efficient without sacrificing patient care.

How do you and your office handle records requests? If you’re playing ostrich and hoping that if you ignore them, they will somehow go away, you’re setting yourself up for a fall.

Patient intake forms are not just a way to waste time or paper- they are a way to begin the conversation of how the practice will be able to help the patient.

Here are some tips to raise your level of documentation and reduce your risk of finding out the hard way that your documentation does not rise to the level necessary to pass a third-party payer audit.

Good communication will enhance the doctor-patient relationship. Keep your ears open to hear how you can best help your patients.

There comes a point in the doctor-patient relationship when the doctor has done all they can, and it is in everyone’s best interest to refer a patient out to another provider. Your documentation needs to address the referral process since it is an important part of the patient’s story.