Certified Risk Adjustment Coder (CRC)

What is an effective method for discussing documentation deficiencies with a provider?

1. Have the provider read the coding guidelines prior to your training session

2. Provide the provider examples of his/her documentation and suggested improvements

3. Try to catch the provider between patients so the schedule is not interrupted

4. Start with a summary of your credentials to gain the respect of the provider

The correct answer is: Provide the provider examples of his/her documentation and suggested improvements

Providing the provider with examples of their documentation along with suggested improvements is an effective method for discussing documentation deficiencies. This approach is beneficial for several reasons. First, it makes the feedback specific and actionable. Instead of abstractly pointing out that there are deficiencies, the provider can see exactly what is lacking in their documentation and how they can enhance it. This method also promotes a collaborative atmosphere, as you are not merely critiquing their work but are offering constructive suggestions that they can implement. By presenting real examples, the provider can better understand the expectations and nuances of proper documentation. This practical guidance facilitates an open dialogue and encourages the provider to ask questions or seek clarification, ultimately leading to improved documentation practices. This strategy fosters a positive relationship built on support and education, rather than on criticism or judgment, which can be crucial in a healthcare setting where providers are often pressed for time and may feel defensive about their work.