This information is targeting physicians, non-physician practitioners and their staff who submit claims for services to the Medicare Part B Program.
Key Points/Instruction/What you need to know
• The medical record should be complete and legible.
• The documentation of each patient encounter should include: the date; reason for the encounter; appropriate history and physical exam; review of lab, X-ray data and other ancillary services and, when appropriate, assessment; and a plan of care (including discharge plan, if appropriate).
• Past and present diagnoses should be accessible to the treating and/or consulting physician.
• The reasons for and results of X-rays, lab tests and other ancillary services should be documented or included in the medical record. In many records, the order and/or intent for the service to be performed is missing.
• Relevant health risk factors should be identified.
• The patient’s progress, including response to treatment, change in treatment, change in diagnosis and patient non-compliance should be documented.
• The written plan of care should include, when appropriate: treatments and medications, specifying frequency and dosage; any referrals; patient/family education; and specific instructions for follow-up.
• The documentation should support the medical necessity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making.
• Documentation of the history, exam, and medical decision making should reflect the level of service reported on the Medicare claim. Mistakes continue with providers over coding and under coding patient visits.
• As a best practice, all entries to the medical record should be dated and authenticated by physician/provider signature. Medical documentation with missing or invalid signatures fails to meet the signature requirements.
• The CPT/ICD-9-CM codes reported on the Medicare claim should reflect the documentation in the medical record.
Background
Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. The medical record facilitates:
• The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment and to monitor his health care over time.
• Communication and continuity of care between physicians and other health care professionals involved in the patient’s care.
• Accurate and timely claims review and payment.
• Appropriate utilization review and quality of care evaluations.
• Collection of data that may be useful for research and education.
An appropriately documented medical record can reduce many of the challenges associated with claims processing and may serve as a legal document to verify the care provided, if necessary.