Physician’s Corner: Answering Common Billing & Documentation Questions

Rick Lehman, MD

You’ve made your way to the physician’s corner of the pMD blog, welcome! Here you’ll find information written for physicians, by physicians.

This post is written by Richard E Lehman, MD, Pediatric Critical Care Medicine

Ask any physician why they started practicing medicine; I promise you’ll never get the answer “because I love billing and documentation.” That being said, there’s really no way out of it as it’s part of the business of medicine.  It’s an essential part of the job we all have to deal with on a daily basis, but the more you know and understand about what goes on behind the scenes, the better off you are and the easier it is to do. Unfortunately, many physician’s billing questions often go unanswered or are told “if it isn’t broken, don’t fix it.”  Some just do the bare minimum to get by and are fine with the reimbursement, others question the whole system and what we can do to improve it.

Full disclosure, I’m not a biller. I am, however, a pediatric critical care physician who has spent over 20 years asking a lot of questions and identifying ways to minimize my administrative and clerical burdens, while still maximizing potential revenues. I’m here to pass on some of that knowledge and provide answers to a few questions commonly asked by physicians regarding billing and documentation I've heard over the years.


I hear providers asking this question a lot. Will my reimbursement change based on the number of diagnoses codes I use, and if so, how much will it increase per diagnosis? The short answer is no, the number of diagnosis codes won’t change the amount paid for a procedure. But this doesn’t quite tell the whole story. The natural follow-up question from providers is often “then can I save myself some time and only put one diagnosis code?” I asked this same question myself and have been told it’s not a great idea. If we routinely underreport diagnoses, we could find ourselves in some trouble with Medicaid payers if we get audited.  If payers are receiving some bundle of payment from the government based on the patient’s risk profile and they then under-report risk based on our under-reported diagnoses, it can result in hefty fines. So, although it may take a little bit of extra time, it’s usually a best practice to report dx codes accurately, with the most predominant one, typically most severe, first.


This is a really interesting question. Will you actually make more money if a bill is submitted and processed today, versus days or weeks later? Well, one smart director of coding explained it simply, a bird in the hand is worth two in the bush…or so the saying goes. When it comes down to it, the longer it takes to collect, the less the money is worth. While we’ll normally get paid the same per our contracts as long as we file within the claims time limit, which can range from 60-365 days depending on the payer, at the end of the day the money is worth more the longer we have it in our pocket. So, ultimately the quicker you can get your billing submitted and processed, the quicker claims can be collected, and the more the money could potentially be worth.


Although time-consuming, poor documentation can significantly impact reimbursement amounts. Avoiding some common documentation mistakes can mean the difference between a claim being rejected or achieving maximal reimbursement. For example, failing to completely describe an assessment and plan, can derail a claim. Physicians sometimes assume an auditor can review lab values and understand what they were trying to do. They can’t. Since they’re not physicians, they’re not allowed to make those assumptions. If you’re looking for your maximum reimbursement, it’s important to include what diagnostic values were run and how they factor into your decision making. Document what you were thinking, what you reviewed, and what you plan to do about it. While not an exhaustive list by any means, other common documentation mistakes that can lead to missed revenue include:

  • Using an incorrect date of service, which tends to happen when notes are retroactively created late
  • Failing to include total time spent for a time-based service
  • A sparse history and exam or exam template that wasn’t individualized and conflicts with other areas of the medical record
  • Failing to sign a note, although this has become far less common these days
  • Providing an incomplete sedation record

Overall, when it comes to maximizing your revenue there’s a ton of variance in best practices depending on your specialty, state, payer contracts, etc. I encourage everyone to ask questions and keep yourself informed as much as possible.

If you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

Dr. Rick Lehman is a veteran critical care physician, providing care to pediatric patients across the country. He’s “grown-up” with the changes in health care over the last 20 years related software and has been directly involved with implementing new EMR systems at multiple hospitals, often transitioning them from paper to digital systems. His frustrations surrounding inefficient EMRs while managing his critical care patients have driven his passion for changing these health care systems to create better provider workflows.

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealth, and secure communication software and services, please contact pMD.

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