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Documentation and the Medical Record Chapter 7. 2 Learning Objectives Define Define the term medical record. connection medical record insurance billing.

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Presentation on theme: "Documentation and the Medical Record Chapter 7. 2 Learning Objectives Define Define the term medical record. connection medical record insurance billing."— Presentation transcript:

1 Documentation and the Medical Record Chapter 7

2 2 Learning Objectives Define Define the term medical record. connection medical record insurance billing process. State the connection between the medical record and insurance billing process. medical information Recite principles for the release of medical information for various situations medical record documentation Explain reasons for medical record documentation reports Name various types of reports that make up a medical record. medical review audit medical records entails. Name various types of medical review and state what an audit or medical records entails. techniques confidentiality Explain techniques used to maintain confidentiality of faxed documents.

3 Chapter 73 Learning Objectives subpoena witness records. Respond appropriately to the subpoena of a witness and records. purpose compliance program recite elements a successful program. Express the purpose of a compliance program and recite elements that lead to a successful program. ways prevent legal problems lawsuits State ways to prevent legal problems and lawsuits Performance Objectives Performance Objectives date of service, place of service, and elements of a history and physical examination (subjective & objective information) chief complaint, symptoms, diagnosis, and procedure or service. Abstract data from the medical record, including date of service, place of service, and elements of a history and physical examination (subjective & objective information) chief complaint, symptoms, diagnosis, and procedure or service.

4 Chapter 74 Key Terms Attending physician audit backup comorbidity Compliance program Concurrent care Consulting physician Continuity of care documentation external audit family history (FH) History of present illness (HPI) internal review medical record

5 Chapter 75 Key Terms medical necessity morbidity mortality objective finding ordering physician past history (PH) performing physician physician examination (PE or PX) referring physician review of systems (ROS) social history (SH) subjective information subpoena treating physician

6 Chapter 76 The Medical Record Medical Record Documentation Guidelines Foundation Understanding the Medical Record and Documentation Guidelines is the Foundation to learning the skill of medical record abstraction. This skill takes time to learn and improves each time it practiced. Medical Record foundation Developing a methodical system to abstract information from a Medical Record is the first step in mastering this job skill after the basic foundation has been laid.

7 Chapter 77 The Medical Record Medical Record Legal Document facts events A Medical Record can be defined as a Legal Document displaying written or graphic information detailing facts and events during the rendering of patient care.

8 Chapter 78 Abstracting Information Abstracting Information from a Medical Recording Information to Complete an Insurance Claim Form Date of Service (DOS) Place of Service (POS) Type of Service (TOS) Diagnosis (dx or DX) and; Procedures & Services

9 Chapter 79 Abstracting Information Abstracting Information from a Medical Recording Procedure & Diagnostic Code Key to substantiating Procedure & Diagnostic Code selection for Reimbursement: Documentation (must be) Accurate,legible,specific,clear,concise Accurate, legible, specific, clear, and concise Must have sufficient detail to describe the level of service provided & all procedures performed

10 Chapter 710 Abstracting Information Abstracting Information from a Medical Recording Sending a Letter to Justify a Health Insurance Claim When submitting a health insurance claim form Medical Insurance Billing Specialist When submitting a health insurance claim form the Medical Insurance Billing Specialist makes decision as to whether additional documentation is needed to substantiate the claim Additional documentation include: Chart notes, Chart notes, Operative report, Operative report, or Discharge summary Discharge summary

11 Chapter 711 Abstracting Information Abstracting Information from a Medical Recording Request from an Insurance Company Insurance companies may request information about: Pre-exiting conditions specific diagnoses Or because the patient is applying for some type of insurance. Sufficient detail to describe the level of service provided & all procedures performed To avoid liability have physician read information to verify that the information is accurate. “Please Read”. Send the information to the Insurance Company with a note to state. “Please Read”.

12 Chapter 712 Photocopying Photocopying the Medical Record Insurance Company Sent a duplicating service to the physician’s office to photocopy records Standard time is set aside in the physician’s office for this service Remove records to be copied from the chart Have the physician review the records, and consent or authorization Be sure a consent or authorization is in place to release medical information. Advise the photocopy company of the standard fee prior to duplicating records. 99080. If information communicated in the records are beyond standards, physicians can request a fee based on the length of report or form, and bill using CPT code 99080.

13 Chapter 713 The Documentation Process SOAP (S) Subjective Information (S) symptoms. Reason for the encounter, chief complaint, symptoms. (O) Objective Findings (O) Facts and finding. physical exam,x-rays,laboratory and other diagnostic tests Data from physical exam, x-rays, laboratory and other diagnostic tests After all Objective Information is Obtained: (A) & (P) After all Objective Information is Obtained: (A) & (P) Assessessubjectiveobjective The Physician Assesses the subjective and objective information Treatment Plan. Put it all together, and formulates a diagnosis and a Treatment Plan.

14 Chapter 714

15 Chapter 715

16 Chapter 716 Record Systems Three basic types of record systems used by most physician’s offices: 1.The problem-oriented record 2.The source-oriented record 3.The integrated medical record subjective & objective assessment treatmentplan. Each system incorporates subjective & objective information, along with the assessment of the patient and the formulation of a treatment plan.

17 Chapter 717 Record Systems 1.Problem-Oriented Record System (POR) organizes information within the medical record POR system organizes information within the medical record according to patient problems. Four parts of the system include: A database Problem list Initial plan and Progress notes

18 Chapter 718 Record Systems 2.Source-Oriented (SOR) according to its source, according to the practitioners SOR system the most common paper-based management system, arranges information in the medical record according to its source, or according to the practitioners who are the source of the treatment, as well as of the data collected. Advantage speed Is the speed which a specific sheet of information can be located Disadvantage: The lack of a clear picture portraying a specific patient problem, filed in different sections The lack of a clear picture portraying a specific patient problem, because the documentation related to it is filed in different sections of the medical record

19 Chapter 719 Record Systems 3.Integrated Medical Record files all documents in chronological order, Integrated medical records files all documents in chronological order, regardless of their source. Each episode of care is clearly defined by date, except laboratory test results. Depending on the practice: Laboratory Test Results/Reportsare defined in a separate section of the medical record. Laboratory Test Results/Reports are defined in a separate section of the medical record.

20 Chapter 720 Documentation chart notesmedical reports; medical record prescription refills, telephone calls, other pertinent data. Documentation - details chronologic recording of pertinent facts and observations about a patient’s health, as seen in chart notes and medical reports; entries in the medical record such as prescription refills, telephone calls, other pertinent data.

21 Chapter 721 Documentation Methods of Documentation: Handwritten Computer Input Dictation & Transcription

22 Chapter 722 Documentation Physician’s title defined in the Medical Record: Physician’s title defined in the Medical Record: Attending Physician – refers to the medical staff member who is legally responsible for the care and treatment given to a patient Consulting Physician – is a provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician.

23 Chapter 723 Documentation Attending Physician Ordering Physician – is the individual directing the selection, preparation, or administration of tests, medication, or treatment. The Attending Physician can also be the ordering physician. Referring Physician – is a provider who sends the patient for testing or treatment. Treating or performing Physician – is the provider who renders a service to a patient.

24 Chapter 724 Documentation Medical Record Fraud Fraudulent Act Tampering with a medical record is a Fraudulent Act Considered a criminal offense Sanctions can include a monetary fine, prison time or both. Litigation Scientific test Scientific test can be done to determine the record’s validity. Paper ink Paper and ink can be analyzed Writing instruments indentation Writing instruments can be determined, and indentation analyzed to determine if alterations took place.

25 Chapter 725 Reason Reason for Documentation Avoidance Avoidance of denied or delayed payments by insurance carriers who investigate the medical necessity of service. Enforcement Enforcement of medical record-keeping rules by insurance carriers who require accurate documentation that support procedure and diagnostic codes Subpoena Subpoena of medical records by state investigators for review by the court Defense Defense of a professional liability claim.

26 Chapter 726 General Principles General Principles of Medical Record Documentation HCFA “Center for Medicare and Medicaid Services (CMS)”, Evaluation & Management1995, 1997 Documentation Guidelines were developed by HCFA (Health Care Financing Administration) Now known as “Center for Medicare and Medicaid Services (CMS)”, for Current Procedural Terminology (CPT), Evaluation & Management services in 1995, and later modified in 1997.

27 Chapter 727 General Principles General Principles of Medical Record Documentation Development of Guidelines Came from auditing by Medicare of physicians’ medical recordsand discovering that the quality of documentation needed to be improved. Came from auditing by Medicare of physicians’ medical records and discovering that the quality of documentation needed to be improved. Medical Necessity The Medical Necessity of procedures and services that had been performed were not stated clearly in the medical record.

28 Chapter 728 General Principles General Principles of Medical Record Documentation Medical Necessity servicesprocedures diagnosis,standards of good medical practice Medical Necessity – the performance of services or procedures are consistent with the diagnosis, in accordance with standards of good medical practice performed at the proper level, and provided in the most appropriate setting. questioned If a treatment is questioned as to whether it is medically necessary, the authorization to perform the treatment or the payment may delayed or denied.

29 Chapter 729 General Principles General Principles of Medical Record Documentation E/M Documentation Guidelines For E/M: Detailed and lengthy They state all the elements necessary to keep a complete record on the patient States chart entries should be dated and signed including what each encounter should contain Which diagnoses need to be stated The patient’s health risks, the patient progress What role consulting physicians have in the care and treatment of the patient How treatment plans should be written

30 Chapter 730 General Principles General Principles of Medical Record Documentation Documentation Guidelines For E/M (Cont): Procedure & Diagnostic Procedure & Diagnostic codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record Documentation Documentation in the medical record should be written at a level that a clinical peer could determine if the services have been accurately coded. abbreviations A list of commonly used abbreviations should be complied and posted throughout the office to ensure consistency when documenting the medical record Chart Chart entries should be dated, and signed including the title or position of the person signing Write Write neatly, & use a permanent, not water-soluble, ink pen (legal copy pen)

31 Chapter 731 General Principles of Medical Record Documentation Corrections to the Medical Record legal copy pen Use a legal copy pen and cross-out incorrect entry using a one single line Write Write the correct information and then date and initial the entry Malpractice If pending, never erase, white-out, or use self-adhesive paper over any information recorded on the patient record. Documentation should answer questionsnot raise them! Documentation should answer questions, not raise them!

32 Chapter 732 General Principles General Principles of Medical Record Documentation Missing Documentation An addendum may be preferable. Addendum to the chart should include the original chart note that is being added to and the date it was prepared/transcribed Signed by the physician or the person adding additional documentation Addendum should be entered in or attached to the chart after the last entry. (see Fig. 7-3, page 178) If there are entries between it and the original entry, a cross-reference at the original entry should be noted (see Fig. 7-3, page 178)

33 Chapter 733 General Principles (Medical Terms used in Documentation) General Principles of Medical Record Documentation (Medical Terms used in Documentation) is the provision of similar services to the same patient by more than one physician on the same day.presence of a separate physical disorder at the same time as the primary admitting diagnosis. Medical Terms used in Documentation Concurrent Care – is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. Usually, there is the presence of a separate physical disorder (heart, arrhythmia) at the same time as the primary admitting diagnosis. Example: Example: A General Internist admitted the patient for diabetes and request a cardiologist to follow the patient’s arrhythmia. When billing the insurance company for services, both physicians’ services must be identified on the claim form to avoid duplication and denial of services.

34 Chapter 734 General Principles (Continuity of Care) General Principles of Medical Record Documentation (Continuity of Care) Continuity of Care – Continued treatment of a patient who is referred by one physician to another for the same condition. Example: Example: If a cancer patient receives chemotherapy treatment from his or her oncologist and is then referred to a Radiologist for radiology treatment, both physician’s are responsible for providing arrangements for the patient’s continuing care. referring physicianprovide records to the Radiologist. The referring physician (Oncologist) must provide records to the Radiologist. provide a reasonable appointment time & follow-up to ensure that records needed to perform the service are in his or her possession. The Radiologist must provide a reasonable appointment time & follow-up to ensure that records needed to perform the service are in his or her possession.

35 Chapter 735 Components Components of A Medical Record Medical Record – Written or graphic information documenting facts and events during the rendering of patient care. Operative Reports – consent to perform special treatment or services.

36 Chapter 736 Components Components of A Medical Record Content of a Medical Report based upon: Complexity of service New PT Established PT Documentation of History Based on 1997 Guidelines History CC CC (chief complaint) HPI HPI (history of present illness) ROS ROS (review of systems PFSH PFSH (past, family, and/or social history)

37 Chapter 737 Components of A Medical Record History brief statement, Chief Complaint – a brief statement, in the patient’s own words, describing the reason for the encounter; such as a symptom, problem, condition, or finding. chronological description History of Present Illness – is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. an inventory Review of System – is an inventory of all body systems obtained through a series of questions that are used to identify signs and/or symptoms that the patient has experienced or might be experiencing.

38 Chapter 738 Components Components of A Medical Record (PFSH) – consist of: Past, Family, and Social History (PFSH) – consist of: (PH) Past History (PH) – patient’s past experiences with illness, operations, injuries, and treatment (FH) Family history (FH) – review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk. (SH) Social history (SH) review of past and current activities depending on patient’s age. Documentation of Physical Exam (PE or PX) organ systemsbody areas Physical examination (PE or PX) – consist of the physician’s findings by examination and/or test results of organ systems or body areas. The Extent of the exam depends on the clinical judgment and the nature of the presenting problem(s).

39 Chapter 739 Components Components of A Medical Record Documentation of Medical Decision-Making number of diagnoses treatment optionsamount and/or complexity of data risk of complication morbiditymortality The physician must look at the number of diagnoses and treatment options, the amount and/or complexity of data to be reviewed, and the risk of complication and/or morbidity or mortality. Morbidity – diseased condition or state Mortality – number of deaths in a given time or place Comorbidity – underlying disease or other condition present at the time of the visit.

40 Chapter 740 Components Components of A Medical Record Documentation for Requesting Outpatient Services When a physician orders outpatient services to be done at another facility, documentation on the order must include: Date of order Patient’s name Service ordered Diagnosis or signs/symptoms Physician’s signature

41 Chapter 741 Legalities Legalities of a Medical Record Consent Consent form must be signed and in patient’s medical record Faxing Confidential Information (The American Health Information Management Association)“should not be used for routine transmission of patient information.” AHIMA (The American Health Information Management Association) advises that fax machines “should not be used for routine transmission of patient information.”

42 Chapter 742 Legalities Legalities of a Medical Record AHIMA recommends that documents should be faxed only when: Hand or mail delivery will not meet the needs of immediate patient care or; Required by a third party for ongoing certification of payment for a hospitalized patient.

43 Chapter 743 Legalities Legalities of a Medical Record Fax Machines must be secure or restricted access. A cover sheet must be used with the transmission. It must contain: Date, Name of sender with fax & telephone number Name of recipient with fax & telephone number Total number of pages, including cover sheet Statement privileged & confidential.

44 Chapter 744 Legalities Legalities of a Medical Record What not to Fax (status of) Financial Financial information & documents containing information on sexually transmitted diseases o Drug or alcohol treatment (HIV) Human Immunodeficiency virus (HIV) Psychiatric records

45 Chapter 745 Legalities Legalities of a Medical Record Transmittal Destination To ensure Fax has reached correct destination: Arrange a scheduled time for transmission with the recipient. Telephone the destination to verify receipt. Request that the authorized receiver sign and return an attached receipt form at the bottom of the cover sheet after receiving the faxed information. coded mail box Send the fax to a coded mail box that only allow a receiver who has the code that was used to fax the information to activate the printer. name patient’s Social Security number Arrange with the recipient to block out the name of the patient’s Social Security number

46 Chapter 746 Legalities of a Medical Record Faxing Legal Documents Criterias are the same for faxing confidential documents, except: The attorney must be consulted to make sure that the documents (contracts, proposal, etc) requiring signatures are legally binding if faxed. Subpoena Must have the physician prior approval The attorney usually employs a person or a duplication service to photocopy records that are under subpoena. Prevention of Legal Problems “Prevention of Lawsuits” Insurance Billers must follow guidelines topic entitled “Prevention of Lawsuits”

47 Chapter 747 Data Storage Medical Record Retention State Local Laws Preservation of medical records is governed by State and Local Laws. Policy of Physicians To retain medical records of all living patients, indefinitely x-ray films, laboratory reports, and pathologic specimens Records such as x-ray films, laboratory reports, and pathologic specimens probably should also be kept indefinitely Deceased patients’ charts Deceased patients’ charts should be kept for at least 5 years. Calendars, appointment books and telephone logs Calendars, appointment books and telephone logs should be filed and stored.

48 Chapter 748 Data Storage Financial Document Retention Keep Tax Records for 7 years And Tax returns permanently A federal regulation mandates: Medicaid Medicare that assigned claims for Medicaid and Medicare be kept for years. Destruction of Medical Records Shred no longer needed patient’s name, date of birth, SS#, date of last visit, date destroyed Maintain a log of all destroyed records, showing the patient’s name, date of birth, SS#, date of last visit, and date destroyed

49 Chapter 749 Auditing Auditing a Medical Record methodical examination reviewinspect,analyze, scrutinize Audit – is a formal, methodical examination or review done to inspect, analyze, and scrutinize the way something is being done (e.g., bookkeeping practices, medical record documentation, insurance claim filing practices). The purpose of an audit verify that the documentation support the services and procedures Is to verify that the documentation support the services and procedures that are being submitted to the patient or insurance carrier for payment and that proper care is being provided.

50 Chapter 750 Auditing a Medical Record Point System During performance of an Audit a Point System is used: Points are awarded only if documentation is present for elements required in the medical record Point Systemshow where deficiencies occur in medical record documentation. The Point System is used to show where deficiencies occur in medical record documentation. evaluate substantiate diagnostic procedure codes. Also used to evaluate and substantiate proper use of diagnostic and procedure codes. Managed Care Organizations (MCO), Government & Private Insurance carriers Managed Care Organizations (MCO), Government & Private Insurance carriers who have a contract with physicians have the right to audit medical records and may claim refunds in the event of accidental or intentional miscoding. improper coding patterns If improper coding patterns exist and are not corrected, the provider of service will be penalized.

51 Chapter 751 Auditing Auditing a Medical Record Billing patterns that may draw attention for a possible Audit: Intentional billing for unnecessary services Incorrect billing for services of physician extenders (e.g., nurse practitioner, physician assistant) Diagnostic testing billed without a separate report in the medical record. Dates of service changed on insurance claims in order to comply with policy coverage dates Co-payments or deductibles waived without good reason and documentation

52 Chapter 752 Auditing Auditing a Medical Record Billing patterns that may draw attention for a possible Audit: (cont) Discounts given illegally Excessive diagnostic tests ordered Provider identification numbers misused resulting in incorrect billing (e.g., two different provider numbers used to bill the same service for the same patient) Improper Modifiers used to obtain financial gain Overpayments not returned to the Medicare program

53 Chapter 753 Auditing a Medical Record Internal Review Two types Two types of Internal review: before 1.Prospective Review – done before billing is submitted. completed encounter forms service/procedures Done to verify that completed encounter forms match all patients seen according to the appointment schedule and all service/procedures have been posted on the day sheet. procedures/services diagnoses All procedures/services and diagnoses listed on the encounter forms are then matched with the data on the insurance claim forms. after 2.Retrospect Review – done after the billing 15 to 20 2 to 4 months Done by randomly pulling 15 to 20 medical records from the last 2 to 4 months and reviewing them to determine whether there is a lack of documentation.

54 Chapter 754 Auditing Auditing a Medical Record External Audit – is a retrospective review (review done after claims have been billed) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraudulent and abusive billing practices.

55 Chapter 755 Auditing Auditing a Medical Record Compliance Program – is a Management Plan composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical record keeping that fulfills official requirements. Developed in 1997 The Concept ask physicians to volunteer to develop & implement compliance programs in their offices. The Goal of a compliance program is to improve the quality of care to patients, control claim submissions, and reduce fraudulent insurance claims, abuse, waste and the cost of healthcare to federal, state, and private health insurers.

56 Chapter 756 Auditing Auditing a Medical Record Benefits of a Compliance Program: Effective internal procedures that ensure compliance with regulations, payment policies, and coding rules Improved medical record documentation Reduction of denied claims Reduced exposure to penalties (cont’d…)

57 Chapter 757 Auditing Auditing a Medical Record ( Avoidance of potential liability stemming from non-compliance Streamlined practice operations through comprehensive policies and improved communication. REMEMBER THE GOLDEN RULE! NOT DOCUMENTED, NOT DONE!


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