Documentation for Proper Coding


Format: Live Webinar
Presenter: Arlene Maxim
Event Date: 12/02/2020
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
Duration: 60 minutes



ICD 10 is complex. Securing accurate information from the physician, as well as, in the appropriate OASIS assessment is critical. However, we often forget to document ICD-10 supporting information within the clinical record. Documentation must ‘paint a picture’ of the patient’s condition. Being certain that we have the correct information is critical. We must assure that the record reflects information relative to the coding applied and that the care in “reasonable and necessary”. We need to remember that “reasonable and necessary” documentation drives every patient encounter. Our payment depends on it. Coding and documentation should “tell the patient story” and why homecare and why now.

Our coding must be documented at the highest level of specificity and our documentation must tell that story.  Think of every admission and subsequent care as a book that is being written. You might consider that the coder is “painting a picture” on the front of a book based on the Start of Care assessment. The clinician is then needed to write the story within the “book” to show Medicare and other payors why the claim ‘story’ told should be paid.

This webinar will help clinicians what should be included in the clinical documentation. The presentation will include documentation that must be included in the face to face information from the physician and that necessary from the clinician.

Learning Objectives:

  1. Why ICD-10 coding is critical to reimbursement
  2. Identify 4 items to assure qualified Face to Face documentation from the physician
  3. Identify 3 main reasons we provide documentation
  4. Identify the 5 most important items to always include in visit notes
  5. Identify at least 3 pieces of documentation that support coding
  6. Identify potential roadblocks in complete documentation for appropriate coding

Areas Covered in the Session:

  1. ICD 10 importance
  2. Need for detailed narrative to support coding
  3. The role intake should take in documentation process
  4. Reasons for excellence in documentation
  5. Reasons for not depending on EMR’s for adequate documentation
  6. Live Q&A Session

Suggested Attendees:

  1. Agency owners
  2. Agency administrators
  3. Physicians
  4. Billers
  5. Coders
  6. ALL Agency clinicians (RN’s, LPNs/LVN’s, PT, OT, ST-INTAKE)
  7. Physicians who refer to home health

About the Presenter:

Arlene Maxim counts 32 years as a home health agency owner, administrator, and consultant, though her nursing career began well before that. Arlene has done extensive research in outcome management using clinical documentation and specific elements. She is now the VP of Program Development for QIRT (Quality In Real Time), a New York-based company with two offices in Michigan and one in Alabama. QIRT is an industry-leading provider of home health and hospice coding and consulting services. Serving agencies across the United States, QIRT provides quality assurance oversight, coding/assessment reviews, clinician education, plus clinical and financial consulting to home care, hospice, and post-acute care agencies.

After Registration

You will receive an email with login information and handouts (presentation slides) that you can print and share to all participants at your location.

System Requirement

Operating System: Windows any version preferably above Windows Vista & Mac any version above OS X 10.6
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to talk and hear clearly

Can’t Listen Live?
No problem. You can get access to On-Demand webinar. Use it as a training tool at your convenience.

For more information you can reach out to below contact:
Toll-Free No: 1-302-444-0162