"Since 2021, there have been significant changes made to documentation and billing, where now our documentation can be more focused," says Jyoti Chouhan, DO, PharmD, FACS.
At the 2023 American Urological Association (AUA) Annual Meeting, Sarah Hecht, MD, and Jyoti Chouhan, DO, PharmD, FACS, delivered a course titled, “Work smarter, not harder– improving clinical efficiency.” In this video, Dr. Chouhan highlights a takeaway from the course in regard to billing and coding. Chouhan is an assistant professor of urology at Oregon Health & Science University in Portland.
For many years, prior to 2021, providers were asked and basically forced to add information in the chart for billing purposes that wasn't always relevant to what the patient was coming in that day to talk about. Some examples of that would be a 14-point review of system and a family history. Since 2021, there have been significant changes made to documentation and billing, where now our documentation can be more focused. Billing on a clinic or outpatient standpoint is determined by the time we spend on patient care that day, or our medical decision-making. That allows 2 things with the shorter notes. One is there's less time charting, hopefully, and the second one is it takes up less time to find information in a note because it's not as long anymore.
This transcription has been edited for clarity.