Coding Accuracy in Clinical Documentation

Coding accuracy is the most important facet of hospital billing.  All clinical documentation should reflect accurate descriptions and diagnoses of the patient.  However, there is a huge breakdown between physicians and coders in the industry.  Robert Gold, MD of DCBA, Inc., is arguably the most recognized proponent of getting physician buy-in to accurate clinical documentation.  His company, DCBA, Inc., provides implementation of a Clinical Documentation Improvement Program which teaches physicians to more accurately document disease process and severity of illness.  If physicians don’t “buy in” to the program, the clinical documentation will not improve.  The approach DCBA brings is unique as it stands up to industry changes such as the implementation of ICD-10.

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