Amidst the blustery Chicago weather, the ASCO Pre-Annual Meeting Seminars are well underway! As I sit back and reflect upon the different sessions I attended on Thursday at the Clinical Care in Oncology for the Advanced Practice Provider Seminar, I feel fortunate to be surrounded by so many talented clinicians and grateful for the opportunity for us all to come together at the ASCO Annual Meeting.
In his keynote address on Thursday, Michael Powe of the American Academy of Physician Assistants underscored the importance of what I would call getting back to basics. By this, I am referring to documentation. We know the inherent problems associated with suboptimal documentation. Arguably, there could not be a better time for us to really examine how and what we document and ensure we are fully in compliance.
As a student, a wise surgical fellow once told me that a progress note is not merely an obligation but rather, it is a vital source of communication about the care of the patient. And we know this to be true yet Mr. Powe relayed that 85% of overpayments occur in the inpatient setting with the weight of the problem being insufficient documentation to support the CPT billing codes being utilized.
With the increasing scrutiny of this issue, it is essential that we appropriately document the care that is provided to our patients. And just as the peril of over-billing exists, so does the peril of under-billing. In this era of uncertainty regarding what changes health care reform will bring with regard to reimbursement, proper documentation not only serves as a critical communication tool for clinicians but also as a cornerstone of quality.
As billing and coding become increasingly complex, we will need to equip ourselves with the knowledge needed to navigate within this progressively intricate environment. Informative websites on billing and coding include the Centers for Medicare & Medicaid Services website
I welcome you to share your thoughts and comments on improving the quality of our documentation!