Clinical Documentation
Documentation in the medical record of a patient’s symptoms, diagnosis and treatment plan (including lab and other test requests and results), and all procedures and services provided, is a critical step in the claims revenue cycle. An appropriately documented patient medical record can reduce many of the hassles associated with claims processing. It may also serve as a legal document to verify the care is provided. The major health care and health insurance associations, including the AMA, have compiled a list of ten things physicians and practice staff should keep in mind when recording information. Access the Principles of documentation below.
Access "Prepare that claim" for more information on this topic. "Appeal that claim" and "Follow that claim" were also developed to help physicians and their practice staff to review the efficiency of their current internal claims management process as well as understand the payer’s role in the claims process. These resources contain sample forms and policies that can be adapted to fit the specific needs of a physician practice.This list is availabe in Prepare that Claim on page 19, Table 2.
- The medical record should be complete and legible.
- The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam; review of lab, x-ray data and other ancillary services, where appropriate; assessment; and plan for 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.
- 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 for care should include, when appropriate: treatments and medications, specifying frequency and dosage; referrals and consultations; patient/family education; and specific instructions for follow-up.
- The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making.
- All entries to the medical record should be dated and authenticated.
- The CPT®/ICD-9 codes reported on the health insurance claim form or billing statement should reflect the documentation in the medical record.
Source: Principles of Medical Record Documentation, 1992, American Health Information Management Association, American Hospital Association, American Managed Care and Review Association, American Medical Association, American Medical Peer Review Association, Blue Cross and Blue Shield Association and Health Insurance Association of America.
Electronic Health Records (EHR), also known as Electronic Medical Records (EMR), capture a patient’s medical history in an electronic format that can be maintained and referenced over time. Moving to an electronic format can result in clearer and more accurate medical records, which are readily available to the treating physician, reducing the duplication of testing or delay of treatment. The AMA has developed resources to help you determine if your physician practice is prepared to make the transition and which EHR system best suits your needs.
Access toolkits to help you effectively use key Health Insurance Portability and Accountability Act (HIPAA) electronic health care transactions in your practice, including eligibility, claim status, electronic funds transfer and prior authorization. Don't wait—start experiencing the savings!
Learn how to select a practice management system that will reduce your time spent on manual administrative tasks that occur throughout the claims revenue cycle and replace them with automated solutions.
