“Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to improper payment (not to mention, an injustice to the patient). The next thing you know, the claim fails a Risk Adjustment Data Validation (RADV) or Office of Inspector General (OIG) audit based on insufficient documentation. The final blow is a funding take-back. Physicians know this, but many of them do not know how to document sufficiently to support the eight to 10 (or more) diagnoses they might list in the assessment. This is where the healthcare business professional’s expertise comes into play.”
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