Problem

An Emergency Medicine group was losing significant revenue due to recurring documentation deficiencies. In many cases, visits that could have supported higher billing levels were being down coded because key documentation elements were missing, such as the required language to support independent interpretations.

Action

Brault’s coding and physician education teams worked together to identify the most common documentation gaps and provide targeted, provider-level feedback. Monthly reports were sent to medical directors, while individual providers with higher deficiency volume received guidance on what was missing and how small documentation changes could help ensure they received proper credit for their work.

Result

As providers addressed the deficiencies, the group reduced documentation gaps, improved billing level accuracy, and captured more than 1,200 additional RVUs compared with the same month in the prior year. The improvement translated into hundreds of thousands of dollars in additional reimbursement, while giving leadership clearer visibility into documentation trends and documentation opportunities.

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