Assignment: Differential Diagnoses
Assignment: Differential Diagnoses
Thorough, detailed documentation of diagnosis, differential diagnoses, and comorbidities affect reimbursement and result in accurate coding. In turn, accurate coding results in appropriate and prompt claims payments for physicians and hospitals. More importantly, accurate documentation leads to better and more effective patient care. The quality of data generated from the documentation is increasingly attached to cost efficiency under value-based reimbursement models (Burks et al., 2022). Payers rely on clinical documentation and accurate coding of diagnoses, differential diagnoses, and comorbidities to validate value-based reimbursement. This enhances the requirement to ensure that documentation is complete and accurate.
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Accurate and comprehensive documentation provides the healthcare team with a clear view of a patient’s medical history, current diagnoses, and treatments. However, inaccurate documentation is unfortunate since it can cause adverse consequences for the patient, healthcare providers, and reimbursement. Inaccurate documentation can lead to inaccurate information about patient care leading to poor patient care due to wrong treatment decisions (Bjerkan et al., 2021). This results in poor patient outcomes and reduced patient satisfaction with the care provided. In addition, poor documentation of diagnostic tests and treatment interventions can lead to doubling tests and procedures, resulting in unnecessary, expensive diagnostic tests that increase costs for patients and hospitals.
Inaccurate documentation affects communication among providers, leading to issues with follow-up evaluations and treatment plans. Patients’ records are the basis of argument in the case of medical malpractice litigation. Thus, any inaccuracies in documentation can be detrimental to the provider, causing one to lose their license (Bjerkan et al., 2021). The financial success of a healthcare organization is dependent on accurate documentation. Reimbursements from payers are entirely dependent on a patient’s medical record. If records are not documented correctly, then claims can be denied, and no reimbursement issued, causing financial losses.
References
Bjerkan, J., Valderaune, V., & Olsen, R. M. (2021). Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students. Frontiers in Computer Science, 3, 624555. https://doi.org/10.3389/fcomp.2021.624555
Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 10, 20503121221099021. https://doi.org/10.1177/20503121221099021
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