Insurance Handbook for the Medical
Office
13th edition
Chapter 04
Medical Documentation and the Electronic
Health Record
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved
1
Lesson 4.1
Documentation Basics
1.
2.
3.
4.
Identify the most common documents founds in the
medical record.
List the advantages and disadvantages of an
electronic health record.
Describe the incentive programs established through
federal legislation for adoption of electronic health
records in physician offices and hospitals.
Define meaningful use and compare the
implementation stages.
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved
2
Lesson 4.1
Documentation Basics (cont’d)
5.
6.
7.
8.
Define the various titles of physicians, as they
related to health record documentation.
Explain the reasons that legible documentation is
required.
List the documentation guidelines for medical
services.
Identify the components required for documentation
of an evaluation and management service based on
1997 Medicare guidelines.
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved
3
The Documentation Process
Documentation is “a chronologic detailed
recording of pertinent facts and observations
about a patient’s health as seen in chart
notes and medical reports.”
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4
The Documentation Process
Common medical 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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5
Health Record Systems
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
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6
Electronic Health Records
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
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7
Incentive Programs for Adoption of
Electronic Health Records
Physician Quality Reporting System Incentive
Program
E-Prescribing Incentive Program
Electronic Health Record Incentive Program
Meaningful Use
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8
Meaningful Use
Stage 1: 2011-2012
Stage 2: 2013
Focused on data capture and sharing
Focused on advance clinical processes
Stage 3: 2015
Focuses on improved outcomes
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9
Documenters
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
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10
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
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11
Legalities of Health Record Billing
Patterns
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
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12
Legalities of Health Record Billing
Patters
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
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13
Documentation Guidelines for
Medical Services
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14
Documentation of History
Chief complaint (CC)
History of present illness (HPI)
Review of systems (ROS)
Past, family, or social history (PFSH)
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15
Documentation of History
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16
Documentation of History
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17
Documentation of Examination
Physical examination
Organs systems/body areas – elements of
examination
Types of physical examination
Problem focused (PF)
Expanded problem focused (EPF)
Detailed (D)
Comprehensive (C)
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18
Lesson 4.2
Medical Records
9.
10.
11.
Define common terminology related to medical,
diagnostic and surgical services.
Abstract information from the medical record to
complete a life insurance application.
Describe the difference between prospective and
retrospective review of records.
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved
19
Lesson 4.2
Medical Records (Cont’d)
12.
13.
14.
15.
List examples of documents containing sensitive
information that should not be faxed.
Respond appropriately to the subpoena of a witness
and records.
Identify principles for retention of health records.
Formulate a procedure for termination of a case.
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20
Documentation Terminology
E/M Terminology
New vs. Established
Consultation
Referral
Concurrent care
Continuity of care
Critical care
Emergency care
Counseling
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21
Documentation Terminology
New versus Established Patients
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22
Diagnostic Terminology 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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23
Directional Terms
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24
Directional Terms
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25
Surgical Terminology
Preoperative vs. Postoperative
Simple/intermediate/complex
Undermining
Take down
Lysis of adhesions
Position
Approach
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26
Internal Reviews
Prospective
Prebilling audit/review
Retrospective
Postbilling audit/review
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27
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
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28
Faxing Documents
Medical Document Fax Cover Sheet
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29
Subpoena Process
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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30
Retention of Records
Records Retention Schedule
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31
Termination of Case
Example of a form letter
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32
Prevention of Legal Problems
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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33
Prevention of Legal Problems
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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34
Questions?
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35
