Medical Documentation Chapter 4 Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 Documentation  Documentation is “a chronologic detailed recording of pertinent facts and observations about a patient’s health as seen in chart notes and medical reports.”

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. The Documentation Process  Common medical office documents  Patient registration form  Medication record  History and physical examination notes or report  Progress or chart notes  Consultation reports  Imaging and x-ray reports  Laboratory reports  Immunization record  Consent and authorization forms  Operative report  Pathology report

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Systems of Documentation  Problem-oriented record system  Documents are flow sheets, charts, graphs  Source-oriented record system  Documents stored in sections  Electronic health record system  Collection of medical information about a patient  Difference between EHR and EMR

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Advantages of the EHR  Less physical space required  Automatic data capture  Available data for other purposes  Easier authentication  Automatic insurance verification  Automated/computer-assisted coding  Batch transmittal of insurance claims  Complete online management

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Documenters  Physicians handwrite or dictate notes from the patient visit  A transcriptionist or correctionist may assist with entering the notes  Receptionist/medical assistant will enter administrative information  Insurance billing specialist enters code and/or claim information

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Types of Physicians  Attending physician  Consulting physician  Non-physician practitioner (NPP)  Ordering physician  Primary care physician (PCP)  Referring physician  Resident physician  Teaching physician  Treating or performing physician

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Reasons for Legible Documentation  Avoidance of denied or delayed payments by insurance carriers investigating the medical necessity of services  Enforcement of medical record-keeping rules by insurance carriers requiring accurate documentation that supports procedure and diagnostic codes  Subpoena of medical records by state investigators or the court for review  Defense of a professional liability claim  Execution of the physician’s written instructions by a patient’s caregiver

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Principles of Documentation  E/M Documentation Guidelines  Medical Necessity  External Audit Point System

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Billing Patterns Causing Possible Audit  Billing intentionally for unnecessary services  Billing incorrectly for services of physician extenders  Billing for diagnostic tests without a separate report in the medical record  Changing dates of service on insurance claims to comply with policy coverage dates  Waiving copayments or deductibles, or allowing other illegal discounts

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Billing Patterns Causing Possible Audit (cont’d.)  Ordering excessive diagnostic tests  Using two different provider names to bill the same service for the same patient  Misusing provider identification numbers, resulting in incorrect billing  Using improper modifiers for financial gain  Failing to return overpayments made by the Medicare program

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Physician Charting Methods

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Physician Charting Methods (cont’d.)

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Contents of a Medical Report  History  Examination  Medical Decision Making

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. History Elements

16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. History Elements (cont’d.)

17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Examination Elements

18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Review/Audit Worksheet Section II

19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Review/Audit Worksheet Section III A

20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Review/Audit Worksheet Section III B

21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Review/Audit Worksheet Section III Part C

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Review/Audit Worksheet Section III

23Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E/M Terminology  New vs. Established  Consultation  Referral  Concurrent care  Continuity of care  Critical care  Emergency care  Counseling

24Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. New vs. Established Patients

25Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Diagnostic Terms and Abbreviations  Most physicians use abbreviations in medical documentation  Eponyms should not be used if another medical term applies  Proper documentation guidelines should always be followed  Documentation should be as specific as possible

26Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Directional Terms

27Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Directional Terms (cont’d.)

28Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Surgical Terminology  Preoperative vs. Postoperative  Simple/intermediate/complex  Undermining  Take down  Lysis of adhesions  Position  Approach

29Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Terminology Used in Coding Procedures

30Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Terminology Used in Coding Procedures (cont’d.)

31Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Types of Internal Reviews  Prospective  Prebilling audit/review  Retrospective  Postbilling audit/review

32Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Audit Prevention  Health Insurance Portability and Accountability Act (HIPAA)  Provisions to combat fraud and abuse in the medical insurance industry  Compliance is mandatory

33Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Elements of a Successful Compliance Program  Written standards of conduct  Written policies and procedures  Compliance officer or committee to operate and monitor the program  Training program for all affected employees

34Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Elements of a Successful Compliance Program (cont’d.)  Process to give complaints anonymously  Routine internal audit  Investigation and remediation plan for problems that develop  Response plan for improper or illegal activities

35Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Software Edit Checks  Software can automatically screen outgoing claims for accuracy  Can prevent errors and flag billing patterns  Documentation may need to be amended with an addendum

36Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medical Record Addendum

37Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Faxing Documents  “Fax” is derived from “facsimile”  State law may prohibit transmitting claim information via fax  Sensitive information should have a cover sheet  Confirm the fax arrived at the destination  Never fax financial information  Consult an attorney regarding the faxing of legal documents

38Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medical Document Fax Cover Sheet

39Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Subpoena  Issued by a judge to obtain witness statements or records  May not require an appearance in person  Never accept a subpoena or give records without the physician’s prior authorization

40Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Records Retention Schedule

41Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Termination of Case Form Letters

42Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Guidelines for Prevention of Lawsuits  Keep patient information confidential.  Report all physician activity which is illegal or unethical.  Be aware of any hazards which may cause injury.  Do not discuss other physicians with patients.  Take the time to explain fees to patients.

43Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Guidelines for Prevention of Lawsuits (cont’d.)  Be sure documentation corresponds with insurance billing.  Be aware of all changes in insurance program guidelines.  Always obtain written consent for records release  Obtain physician authorization before turning an account over for collection.  Always act in a courteous and professional manner.