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Medical Documentation and the Electronic Health Record
Chapter 4
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Discussion Will Include…….
Documentation Basics Legible documentation Principles of documentation Contents of a medical record The Electronic Health Record Terminology Medical record documents Prospective/retrospective reviews External audits Fax confidentiality Subpoena Prevention of lawsuits
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Documentation basics
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If it isn’t documented ___________________________!!!!!
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 If it isn’t documented ___________________________!!!!!
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Common Office Documents
Patient registration (demographic information) 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
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Systems of Documentation
_______________________ record system Documents are flow sheets, charts, graphs Documents stored in sections Collection of medical information about a patient Difference between EHR and EMR
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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 7
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Documenters Physicians handwrite or dictate notes from the patient visit A transcriptionist or correctionist may assist with entering the notes SCRIBES? Receptionist/medical assistant will enter administrative information Insurance billing specialist enters code and/or claim information
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The Need for Legible Documentation
Avoidance of denied or delayed payments by insurance carriers investigating the ___________________________ of services ____________________ of medical record-keeping rules by insurance carriers requiring _________________________________ procedure and diagnostic codes ______________________ of medical records by state investigators or the court for review _____________________ of a professional liability claim _______________________ of the physician’s written instructions by a patient’s caregiver
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Basic Principles of Documentation
E/M documentation guidelines 1995 and 1997 standards Medical necessity ________________________________________ External audit point system Chart auditing scoring system
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Audit-Provoking Billing Patterns
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
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More Audit-Provoking Billing Patterns
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
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SOAP Notes FIGURE 4-3 In a paper-based system, explanation of the acronym “SOAP” used as a format for progress notes defining subjective and objective information, the assessment, and the treatment plan.
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EVALUATION & MANAGEMENT
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Contents of an Office Visit Report
Chief Complaint History Examination Medical Decision Making
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Documentation Key Component: History
Chief Complaint – History of Present Illness - Review of Systems - Past Medical/Family/Social History -
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Documentation Key Component: General Medical Exam
BODY AREAS Head, including the face Neck Chest, including breasts & axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity ORGAN SYSTEMS Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/ immunologic
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Documentation Key Component: Medical Decision Making
Health care management process done after performing a history and physical exam – results in a plan for treatment Number of diagnoses and treatment options Amount or complexity of data to be reviewed Level of risk of complications, morbidity, or mortality
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Discussion Mrs. Ellison called her doctor’s office and spoke with Lorraine about a bill from her recent visit. Mrs. Ellison has been Dr. Johnson’s patient for many years, although prior to her recent visit it had been some time since she saw Dr. Johnson. Mrs. Ellison was sure that there was a billing error because she was billed for a new patient visit. How should Lorraine handle this patient’s inquiry?
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The electronic health record
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E/M Terminology New vs. Established Consultation Referral Concurrent care Continuity of care Critical care Emergency care Counseling
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New vs. Established Patients
FIGURE 4-13 Decision tree for new patient versus established patient when selecting a CPT evaluation and management code.
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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
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Surgical Terminology Preoperative vs. Postoperative
Simple/intermediate/complex Undermining Take down Lysis of adhesions Position Approach
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Audit prevention
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Types of Internal Reviews
Prospective _______________________ Retrospective
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Audit Prevention Health Insurance Portability and Accountability Act (HIPAA) Provisions to combat fraud and abuse in the medical insurance industry Compliance is mandatory
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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
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Elements of a Successful Compliance Program
Process to give complaints anonymously Routine internal audit Investigation and remediation plan for problems that develop Response plan for improper or illegal activities
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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
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Faxing Medical Records
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
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Subpoenas 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
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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
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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.
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Discussion Allison was working at the reception desk during a department staff meeting. She normally worked in medical records and therefore had an understanding of the importance of patient confidentiality. When a caseworker from a worker’s comp case arrived and asked to discuss a patient’s case with the physician, Allison explained that she would need a signed release form from the patient before that was possible. Did Allison handle this situation correctly?
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Homework TEST: October 27 Chapters 1-2-3-4
Read Chapter 7 The Paper Claim: CMS-1500 (02-12)
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