Documentation is Crucial for a successful “Annual Visit” Campaign

November 22, 2018

Blue Cross and Blue Shield of Oklahoma (BCBSOK) continues a preventive care campaign to remind our members to schedule their annual exams. This month, we are encouraging members with asthma to see their health care provider.

We know you see a lot of patients. Since this campaign may add to your patient volume, we wanted to remind you about carefully documenting patients’ medical records.

Careful documentation is needed for proper assignment of ICD-10-CM/PCS codes. To help make sure claims are properly billed and the right benefits are applied, your documentation must paint a complete picture of each patient’s condition.

As you know, medical record data can also be used to help create provider report cards and show meaningful use in electronic health records. Potential patients may use provider profiles, with online comparison tools, to choose where to go for care.

Clinical documentation improvement tools and services are widely available. Regardless of whether you established a clinical documentation improvement (CDI) program, there are some basic CDI tips you can use to help support accurate ICD-10 coding on your claims:

  1. Lay the groundwork by outlining a complete history
  2. Go below the surface by highlighting potential red flags and risk factors
  3. Include progress notes to illustrate how the patient was monitored and evaluated
  4. Put the pieces together with details on why decisions were made
  5. Focus on teamwork between medical, coding and billing staff

Thank you for your efforts to support our members’ health and wellness at their annual visits and all other visits.

Careful medical record documentation will help ensure your claims accurately reflect the care and services you give to our members.

This material is for educational purposes only. Health care providers are instructed to submit claims using the most appropriate codes based upon the medical record documentation and coding guidelines and reference materials.