Issues Regarding Compliance to Coding
Often, therapists do not document all of the examinations that are performed. Therapists rarely document everything because of the information they receive, so they may overlook some services and fail to document them. (Abbey, 2009). However, those services that are not documented will not be paid because they are not there if they are not documented. Supporting documentation is essential when billing for services because the services cannot be paid for without it.
Since the payment and coding system cannot determine which services the therapist chose not to document, those services are rendered invisible to the system. This could be due to human error, or the therapist may have dismissed or forgotten about these services. Everything must be documented to avoid this. The therapist may benefit from delegating authority and responsibilities (Abbey, 2009). Even if the therapist is required to code a service themselves, an assistant can do so as well.
As a result, the assistant’s documentation may have contributed to the therapist overlooking something. Therapists should also train themselves to document as thoroughly and quickly as possible so they do not overlook anything. Special memorization or note-taking techniques can assist the therapist in accomplishing this.
Ways the Organization Can Remain in Compliance
It is critical that the therapist recognizes the significance of this requirement and does not disregard it. To accomplish this, the organization may take disciplinary action against the therapist (Rao, 2020). The organization should notify the therapist that they have overlooked something in their duties and that the system has suffered as a result. The therapist may correctly enter the codes and bill for other services while overlooking the other services. The therapist will be more attentive the next time and will not make the same mistake.
However, it is preferable to implement preventative measures to ensure that therapists do not make coding errors. This includes having the necessary knowledge and practice, monitoring and checking how the therapist does it, and taking additional steps to alert other therapists of potential errors. If one person succeeds, others may follow, so it is critical to try to prevent this from happening in the first place. These organizations can remain compliant if their employees follow the rules and make no exceptions.
References
Abbey, D. (2009). Healthcare payment systems. Taylor & Francis. Web.
Rao, P. R. (2020). Ethical considerations for healthcare organizations. Seminars in Speech and Language, 41(03), 266–278. Web.