Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

August 2018

‘Annual Visit’ Campaign Stresses the Importance of Proper Coding

Blue Cross and Blue Shield of Texas (BCBSTX) is currently conducting a preventive care awareness campaign to remind our members of the importance of scheduling annual visits for routine physical exams. We know you already see a lot of patients, and since this campaign may increase patient traffic to your office, we wanted to take this opportunity to emphasize the importance of careful medical record documentation.

The Importance of Proper Documentation
Careful documentation is critical for proper assignment of ICD-10-CM (code set for diagnosis coding) and PCS (Procedural Coding System) codes. To help ensure claims are properly billed and appropriate benefits are applied, your documentation must paint a clear and complete picture of each patient’s condition with details to support subsequent diagnoses and treatment.

As you know, medical record data is also used to help develop provider report cards and demonstrate meaningful use in electronic health records. Provider profiles may be made publicly available through online transparency or comparison tools, and potential patients may use this information when they are choosing where to go for care.

Documentation Principles
Clinical documentation improvement tools and services are widely available. Regardless of whether your organization or office has implemented a clinical documentation improvement (CDI) program, there are some basic CDI principles you can use to help support accurate ICD-10 coding on your claims, including:

  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.

We appreciate your efforts to support our members’ health and wellness at their annual visits and every visit thereafter. Careful medical record documentation for each patient at every visit will help ensure your claims accurately reflect the care and services you provide to our members.