Watch the Documentation and Coding: Building Your Sundae webinar from the National Nurse-Led Care Consortium.

Watch the Documentation and Coding: Building Your Sundae webinar from the National Nurse-Led Care Consortium. You can also review the slide deck.

https://nurseledcare.phmc.org/past-webinars/item/551-documentation-and-coding-building-your-sundae.html

What were the key points that you learned from the webinar and how will you apply them to practice as an NP?

In your response, make sure to discuss the foundation of reimbursement, the differences in coding by medical decision-making vs time, and APRN value in various payment models."

Key Points from the "Documentation and Coding: Building Your Sundae: A Webinar for Parents and Carers of Children with Learning Differences

 1. Foundation of Reimbursement:

 Understanding Reimbursement Models: The payment for the healthcare services is done depending on the documentation and coding that reveal the nature and the intensity of the services. The core of reimbursement is, therefore, dependent on the documentation of the patient’s condition, the services provided, and the medical judgment used.

 Fee-for-Service vs. Value-Based Care: The webinar discussed the distinction between the fee for service (FFS) and the value based care systems. In FFS, payment is done on the basis of the number of services that are offered in a certain time while in value based care the payment is made depending on the services offered and the impact of the services offered. It is equally important for both, but more so for value-based care because the attention is paid to the quality of care and the results of the patients’ treatment.

 2. Coding by Medical Decision-Making vs. Time:Coding by Medical Decision-Making vs. Time:

 Medical Decision-Making (MDM): MDM coding involves the aspects of patient’s condition and the process of decision making that is made in the care of the patient. It encompasses elements such as the diagnostic outcomes, the volume and level of detail of data assessed, and the likelihood of adverse events. For instance, higher MDM coding is reasonable, when a patient has numerous co-morbid conditions that need significant management.

 Time-Based Coding: This approach of coding is done in relation to the time that is taken in the care of the patient and this includes the time that is spent with the patient and the time that is spent on the documentation and coordination of the patient’s care. Time-based coding is applied when the time taken in the treatment of a patient forms part of the service delivered to the patient. This is especially so where a patient requires a lot of attention and time in the course of treatment.

 Choosing Between MDM and Time: Which one is better: MDM or time-based coding, depends on the type of the encounter. If the emphasis is on the aspects such as the complexity and decision making, then the MDM coding can be used. However, if the time spent with the patient is significant, time-based coding is probably more effective. It is therefore important to determine the right coding method for the service offered to avoid overbilling or underbilling and to be in compliance.

 3. APRN Value in Various Payment Models:APRN Value in Various Payment Models:

 Role of APRNs: In different payment models, APRNs can contribute in the delivery of excellent care at lower costs. The webinar focused on the role of APRNs in increasing positive patient outcomes, addressing comorbidities, and increasing the availability of health care services in the currently underutilized regions.

 Impact on Value-Based Care: In value-based care systems, APRNs are useful because of their capacity to attend to the comprehensive care needs of patients and concentrate on early intervention. These functions include patient education, care co-ordination and chronic disease management and these are very vital in value based care delivery systems.

 Demonstrating Value: APRNs practicing in different payment models should learn how to document and code their services to have the most effect. Documentation of care is crucial in the establishment of the worth of the care offered and in the right remuneration. It is therefore imperative for APRNs to provide evidence of the scope of their practice, the amount of time taken, the complexity of the cases and the results.

 Application to Practice as an NP:Application to Practice as an NP:

 1. Enhance Documentation Practices:

 Ensure that you document the complication of the patient and the services you offer in the right manner. This involves written records on the decision making process made, the time taken and the result of the decision made.

 2. Choose Appropriate Coding Methods:

 For every patient encounter, the provider should decide whether the encounter should be documented with MDM or time-based coding. Make sure that what is coded reflects the services provided which are in relation to the level of the case and the time taken.

 3. Focus on Value-Based Care:

 Some of the trends that should be adopted include focusing on preventive care and chronic disease management in practice to meet the value-based care models. Exhibit the ways in which you enhance the quality of care by documenting and coding the care plans and work done in identifying patients and handling their needs.

 4. Stay Informed and Updated:

 It is crucial to keep up with the new changes in coding and reimbursement to avoid any conflict with the set regulations and get the best billing practices. It is advised that the individual continue his/her education to update the knowledge on the changes in documentation and coding.