By Kelly M. Anastasio, CPC, CPC-H, CPC-P, CPC-I
12/29/2009
Due to the acute nature of the urgent care environment, many elements of accurate documentation are missed, making the practitioner vulnerable to potential revenue loss. The majority of urgent care revenue is driven by evaluation and management (E/M) services and history implies that many urgent care providers are undercoding, which has a negative impact on the financial health of the center.
Most patients enter an urgent care center with new signs, symptoms and uncertain diagnosis which would support the medical necessity for a comprehensive history, thorough examination and an increase in medical decision making. A well-documented patient chart would support an increased level in the E/M code, which would support an increase in reimbursement.
The quality and content of documentation must represent accurately the services rendered. It is recommended that the E/M service be documented clearly and separately from any other services/procedures performed. In the event of an audit or a payor request for supporting documentation, the patient record would identify clearly the separately identifiable services performed, and allow for a prompt reimbursement. Many practices are using templates to aide in proficient and timely documentation, which provide reimbursement results in favor of the physician.
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