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

Medical DocumentationMedical Documentation

Chapter 4Chapter 4

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

Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 22

Learning ObjectivesLearning Objectives Name several systems used when organizing health Name several systems used when organizing health

records in the documentation process.records in the documentation process. Explain reasons legible documentation is required.Explain reasons legible documentation is required. Identify principles of documentation.Identify principles of documentation. State contents of the medical report.State contents of the medical report. Define common medical, diagnostic, and legal terms.Define common medical, diagnostic, and legal terms. List documents required for an internal review of health List documents required for an internal review of health

records.records. Describe the difference between prospective and Describe the difference between prospective and

retrospective review of records. retrospective review of records.


Learning Objectives (cont’d.)Learning Objectives (cont’d.)

State reasons why an insurance company may State reasons why an insurance company may decide to perform an external audit of medical decide to perform an external audit of medical records.records.

Identify principles for retention of health records.Identify principles for retention of health records. Explain techniques used for fax confidentiality.Explain techniques used for fax confidentiality. Respond appropriately to the subpoena of a Respond appropriately to the subpoena of a

witness and records.witness and records. Formulate a procedure for termination of a case.Formulate a procedure for termination of a case. State guidelines for insurance billing specialists State guidelines for insurance billing specialists

for preventing lawsuits. for preventing lawsuits.


Chapter 4Chapter 4

Lesson 4.1Lesson 4.1


DocumentationDocumentation

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


The Documentation ProcessThe Documentation Process Common medical office documentsCommon medical office documents

Patient registration formPatient registration form Medication recordMedication record History and physical examination notes or reportHistory and physical examination notes or report Progress or chart notesProgress or chart notes Consultation reportsConsultation reports Imaging and x-ray reportsImaging and x-ray reports Laboratory reportsLaboratory reports Immunization recordImmunization record Consent and authorization formsConsent and authorization forms Operative reportOperative report Pathology reportPathology report


Systems of DocumentationSystems of Documentation

Problem-oriented record systemProblem-oriented record system Documents are flow sheets, charts, graphsDocuments are flow sheets, charts, graphs

Source-oriented record systemSource-oriented record system Documents stored in sectionsDocuments stored in sections

Electronic health record systemElectronic health record system Collection of medical information about a patientCollection of medical information about a patient Difference between EHR and EMRDifference between EHR and EMR


Advantages of the EHRAdvantages of the EHR

Less physical space requiredLess physical space required Automatic data captureAutomatic data capture Available data for other purposesAvailable data for other purposes Easier authenticationEasier authentication Automatic insurance verificationAutomatic insurance verification Automated/computer-assisted codingAutomated/computer-assisted coding Batch transmittal of insurance claimsBatch transmittal of insurance claims Complete online managementComplete online management


DocumentersDocumenters

Physicians handwrite or dictate notes from Physicians handwrite or dictate notes from the patient visitthe patient visit

A transcriptionist or correctionist may assist A transcriptionist or correctionist may assist with entering the noteswith entering the notes

Receptionist/medical assistant will enter Receptionist/medical assistant will enter administrative informationadministrative information

Insurance billing specialist enters code and/or Insurance billing specialist enters code and/or claim informationclaim information


Types of PhysiciansTypes of Physicians

Attending physicianAttending physician Consulting physicianConsulting physician Non-physician practitioner (NPP)Non-physician practitioner (NPP) Ordering physicianOrdering physician Primary care physician (PCP)Primary care physician (PCP) Referring physicianReferring physician Resident physicianResident physician Teaching physicianTeaching physician Treating or performing physicianTreating or performing physician


Reasons for Legible Reasons for Legible DocumentationDocumentation

Avoidance of denied or delayed payments by Avoidance of denied or delayed payments by insurance carriers investigating the medical insurance carriers investigating the medical necessity of servicesnecessity of services

Enforcement of medical record-keeping rules by Enforcement of medical record-keeping rules by insurance carriers requiring accurate insurance carriers requiring accurate documentation that supports procedure and documentation that supports procedure and diagnostic codesdiagnostic codes

Subpoena of medical records by state Subpoena of medical records by state investigators or the court for reviewinvestigators or the court for review

Defense of a professional liability claimDefense of a professional liability claim Execution of the physician’s written instructions by Execution of the physician’s written instructions by

a patient’s caregivera patient’s caregiver


Principles of DocumentationPrinciples of Documentation

E/M Documentation GuidelinesE/M Documentation Guidelines Medical NecessityMedical Necessity External Audit Point SystemExternal Audit Point System


Billing Patterns Causing Possible Billing Patterns Causing Possible AuditAudit

Billing intentionally for unnecessary servicesBilling intentionally for unnecessary services Billing incorrectly for services of physician Billing incorrectly for services of physician

extendersextenders Billing for diagnostic tests without a separate Billing for diagnostic tests without a separate

report in the medical recordreport in the medical record Changing dates of service on insurance Changing dates of service on insurance

claims to comply with policy coverage datesclaims to comply with policy coverage dates Waiving copayments or deductibles, or Waiving copayments or deductibles, or

allowing other illegal discountsallowing other illegal discounts


Billing Patterns Causing Possible Billing Patterns Causing Possible Audit (cont’d.)Audit (cont’d.)

Ordering excessive diagnostic testsOrdering excessive diagnostic tests Using two different provider names to bill the Using two different provider names to bill the

same service for the same patientsame service for the same patient Misusing provider identification numbers, Misusing provider identification numbers,

resulting in incorrect billingresulting in incorrect billing Using improper modifiers for financial gainUsing improper modifiers for financial gain Failing to return overpayments made by the Failing to return overpayments made by the

Medicare programMedicare program


Physician Charting MethodsPhysician Charting Methods


Physician Charting Methods (cont’d.)Physician Charting Methods (cont’d.)


Contents of a Medical ReportContents of a Medical Report

HistoryHistory ExaminationExamination Medical Decision Making Medical Decision Making


History ElementsHistory Elements


History Elements (cont’d.)History Elements (cont’d.)


Examination ElementsExamination Elements


Review/Audit WorksheetReview/Audit WorksheetSection IISection II


Review/Audit Worksheet Review/Audit Worksheet Section III ASection III A


Review/Audit Worksheet Review/Audit Worksheet Section III BSection III B


Review/Audit WorksheetReview/Audit WorksheetSection III Part CSection III Part C


Review/Audit Worksheet Review/Audit Worksheet Section IIISection III


Chapter 4Chapter 4

Lesson 4.2Lesson 4.2


E/M TerminologyE/M Terminology

New vs. EstablishedNew vs. Established ConsultationConsultation ReferralReferral Concurrent careConcurrent care Continuity of careContinuity of care Critical careCritical care Emergency careEmergency care CounselingCounseling


New vs. Established PatientsNew vs. Established Patients


Diagnostic Terms and Diagnostic Terms and AbbreviationsAbbreviations

Most physicians use abbreviations in medical Most physicians use abbreviations in medical documentationdocumentation

Eponyms should not be used if another Eponyms should not be used if another medical term appliesmedical term applies

Proper documentation guidelines should Proper documentation guidelines should always be followedalways be followed

Documentation should be as specific as Documentation should be as specific as possiblepossible


Directional TermsDirectional Terms


Directional Terms (cont’d.)Directional Terms (cont’d.)


Surgical TerminologySurgical Terminology

Preoperative vs. PostoperativePreoperative vs. Postoperative Simple/intermediate/complexSimple/intermediate/complex UnderminingUndermining Take downTake down Lysis of adhesionsLysis of adhesions PositionPosition ApproachApproach


Terminology Used in Coding Terminology Used in Coding ProceduresProcedures


Terminology Used in Coding Terminology Used in Coding Procedures (cont’d.)Procedures (cont’d.)


Types of Internal ReviewsTypes of Internal Reviews

ProspectiveProspective Prebilling audit/reviewPrebilling audit/review

RetrospectiveRetrospective Postbilling audit/reviewPostbilling audit/review


Audit PreventionAudit Prevention

Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA)Accountability Act (HIPAA) Provisions to combat fraud and abuse in the Provisions to combat fraud and abuse in the

medical insurance industrymedical insurance industry Compliance is mandatoryCompliance is mandatory


Elements of a Successful Elements of a Successful Compliance ProgramCompliance Program

Written standards of conductWritten standards of conduct Written policies and proceduresWritten policies and procedures Compliance officer or committee to operate Compliance officer or committee to operate

and monitor the programand monitor the program Training program for all affected employeesTraining program for all affected employees


Elements of a Successful Elements of a Successful Compliance Program (cont’d.)Compliance Program (cont’d.)

Process to give complaints anonymouslyProcess to give complaints anonymously Routine internal auditRoutine internal audit Investigation and remediation plan for Investigation and remediation plan for

problems that developproblems that develop Response plan for improper or illegal Response plan for improper or illegal

activitiesactivities


Software Edit ChecksSoftware Edit Checks

Software can automatically screen outgoing Software can automatically screen outgoing claims for accuracyclaims for accuracy Can prevent errors and flag billing patternsCan prevent errors and flag billing patterns Documentation may need to be amended with an Documentation may need to be amended with an

addendumaddendum


Medical Record AddendumMedical Record Addendum


Faxing DocumentsFaxing Documents

““Fax” is derived from “facsimile”Fax” is derived from “facsimile” State law may prohibit transmitting claim State law may prohibit transmitting claim

information via faxinformation via fax Sensitive information should have a cover Sensitive information should have a cover

sheetsheet Confirm the fax arrived at the destinationConfirm the fax arrived at the destination Never fax financial informationNever fax financial information Consult an attorney regarding the faxing of Consult an attorney regarding the faxing of

legal documentslegal documents


Medical DocumentMedical Document Fax Cover Sheet Fax Cover Sheet


SubpoenaSubpoena

Issued by a judge to obtain witness Issued by a judge to obtain witness statements or recordsstatements or records

May not require an appearance in personMay not require an appearance in person Never accept a subpoena or give records Never accept a subpoena or give records

with the physician’s prior authorizationwith the physician’s prior authorization


Records Retention ScheduleRecords Retention Schedule


Termination of Case Form Termination of Case Form LettersLetters


Guidelines for Prevention of Guidelines for Prevention of LawsuitsLawsuits

Keep patient information confidential.Keep patient information confidential. Report all physician activity which is illegal or Report all physician activity which is illegal or

unethical.unethical. Be aware of any hazards which may cause Be aware of any hazards which may cause

injury.injury. Do not discuss other physicians with patients.Do not discuss other physicians with patients. Take the time to explain fees to patients.Take the time to explain fees to patients.


Guidelines for Prevention of Guidelines for Prevention of Lawsuits (cont’d.)Lawsuits (cont’d.)

Be sure documentation corresponds with Be sure documentation corresponds with insurance billing.insurance billing.

Be aware of all changes in insurance program Be aware of all changes in insurance program guidelines.guidelines.

Always obtain written consent for records releaseAlways obtain written consent for records release Obtain physician authorization before turning an Obtain physician authorization before turning an

account over for collection.account over for collection. Always act in a courteous and professional Always act in a courteous and professional

manner.manner.

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