Clinical documentation, coding, and billing

Practitioners must be aware of ever-changing requirements for documentation and correct diagnostic and procedural coding for billing. These requirements are often dependent on the setting, and clinicians who practice in more than one setting have to understand multiple regulations and guidelines. Some practices are dictated by the payer, such as precertification or using a specific form (e.g., HCFA 1500) to submit the charges. Documentation of services provided encompasses evaluation reports, treatment plans, recertifications, and discharge summaries. Different forms and formats are required in different settings and by different payers. The clinician must document in a clear and concise format that can be understood by others. When documentation is completed accurately and well, reimbursement for services is more likely.