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Misstep 3: Missing Valuable Charges
Incomplete documentation causes missed charges. This misstep can easily happen in the busyness of a patient visit, especially when instructions are communicated verbally. Common missed charges include labs, blood draws, administration of an injection, x-rays, and the reading of results.
In addition, providers can fail to document units of service (or drug dosage amounts). Quantity of dispensed drugs need to be noted accurately so the correct charge can be stated on the claim. Poor documentation for procedures will cause delayed claim submission or missed reimbursement.
Advice: Teach providers to document commonly missed charges like labs and injections. If your EHR has smart alerts, set these up to remind providers of incomplete procedure documentation when locking charts. Have an easily reviewable list and common conversion table for drug dosage. Keep a log of all requested labs and drugs dispensed; double check these against claim charges.