Chapter 4
Medical Documentation
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Learning Objectives







Name several systems used when organizing
health records in the documentation process.
Explain reasons legible documentation is required.
Identify principles of documentation.
State contents of the medical report.
Define common medical, diagnostic, and legal
terms.
List documents required for an internal review of
health records.
Describe the difference between prospective and
retrospective review of records.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
2
Learning Objectives (cont’d.)






State reasons why an insurance company may
decide to perform an external audit of medical
records.
Identify principles for retention of health records.
Explain techniques used for fax confidentiality.
Respond appropriately to the subpoena of a
witness and records.
Formulate a procedure for termination of a case.
State guidelines for insurance billing specialists
for preventing lawsuits.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
3
Chapter 4
Lesson 4.1
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
4
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.”
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
5
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
6
Systems of Documentation

Problem-oriented record system


Source-oriented record system


Documents are flow sheets, charts, graphs
Documents stored in sections
Electronic health record system


Collection of medical information about a patient
Difference between EHR and EMR
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
7
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
8
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
9
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
10
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
11
Principles of Documentation



E/M Documentation Guidelines
Medical Necessity
External Audit Point System
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
12
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
13
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
14
Physician Charting Methods
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
15
Physician Charting Methods (cont’d.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
16
Contents of a Medical Report



History
Examination
Medical Decision Making
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
17
History Elements
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
18
History Elements (cont’d.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
19
Examination Elements
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
20
Review/Audit Worksheet
Section II
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
21
Review/Audit Worksheet
Section III A
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
22
Review/Audit Worksheet
Section III B
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
23
Review/Audit Worksheet
Section III Part C
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
24
Review/Audit Worksheet
Section III
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
25
Chapter 4
Lesson 4.2
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
26
E/M Terminology








New vs. Established
Consultation
Referral
Concurrent care
Continuity of care
Critical care
Emergency care
Counseling
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
27
New vs. Established Patients
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
28
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
29
Directional Terms
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
30
Directional Terms (cont’d.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
31
Surgical Terminology







Preoperative vs. Postoperative
Simple/intermediate/complex
Undermining
Take down
Lysis of adhesions
Position
Approach
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
32
Terminology Used in Coding
Procedures
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
33
Terminology Used in Coding
Procedures (cont’d.)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
34
Types of Internal Reviews

Prospective


Prebilling audit/review
Retrospective

Postbilling audit/review
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
35
Audit Prevention

Health Insurance Portability and
Accountability Act (HIPAA)


Provisions to combat fraud and abuse in the
medical insurance industry
Compliance is mandatory
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
36
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
37
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
38
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
39
Medical Record Addendum
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
40
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
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
41
Medical Document
Fax Cover Sheet
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
42
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
with the physician’s prior authorization
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
43
Records Retention Schedule
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
44
Termination of Case Form
Letters
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
45
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.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
46
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.
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
47