1. Insurance Handbook for the Medical Office
13th edition
Chapter 04
Medical Documentation and the Electronic Health Record

2. Lesson 4.1 Documentation Basics
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.

3. Documentation Basics (cont’d)
Lesson 4.1
Documentation Basics (cont’d)
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.

4. 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.”
Anything in the patient record is considered “documentation.”

5. 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
Health record: written or graphic information documenting facts and events during the rendering of patient care.
These forms may be kept on paper, on microfilm, or electronically, depending on the system used in the medical office.
A hospital record would also include an attending physician’s orders, date of admission, hospital stay dates, discharge date, and discharge summary.

6. Health Record Systems Problem-oriented record system
Documents are flow sheets, charts, graphs
Source-oriented record system
Documents stored in sections
Electronic health record system
Collection of medical information about a patient
Difference between EHR and EMR
A POR system allows a physician to quickly locate information and compare evaluations.
An SOR system organizes documents into sections, not by data.
The EHR is a collection of medical information about the past, present, and future of a patient that resides in a centralized electronic system. This system receives, stores, transmits, retrieves, and links data from many different information systems. The EMR (electronic medical record) is an individual physician’s personal medical record on a patient. Everything contained in the EMR is contained in the EHR.

7. 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
Computer systems can make data from medical records available for other purposes, to help develop protocols and critical pathways for disease management.
An electronic health record system holds information in a centralized location, giving access to all patient data quickly.

8. 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
American Recovery and Reinvestment Act of 2009 (ARRA) encourages implementation of electronic health records by offering annual financial incentives for qualifying offices that convert to electronic format between 2011 and 2015 or 2016.

9. Meaningful Use Stage 1: 2011-2012 Stage 2: 2013 Stage 3: 2015
Focused on data capture and sharing
Stage 2: 2013
Focused on advance clinical processes
Stage 3: 2015
Focuses on improved outcomes
Meaningful use (MU) is demonstrating that the health care organization has the capabilities and processes in place so that the provider is actively using certified EHR technology to:
Improve quality of care, patient safety, efficiencies in health care, and reduce health disparities
Engage patients and family in management of their care
Improve care coordination and the general public health
Maintain privacy and security of patient health information

10. 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
Discuss each physician type.

11. 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
Why does documentation have to be legible? (To prevent problems with insurance claims and to comply with laws and guidelines related to the medical documentation)

12. 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
Medicare fiscal intermediaries have “walk-in rights” that they may invoke to conduct documentation reviews, audits or evaluations.
Explain which of these problems are also considered insurance fraud. (Falsifying information of any type on a medical record would be considered fraud. Therefore, billing for tests not in the record or changing dates of service on the claim would be considered fraud.)

13. 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
All of these patterns are considered fraud or abuse.

14. Documentation Guidelines for Medical Services
Fig. 4-3

15. Documentation of History
Chief complaint (CC)
History of present illness (HPI)
Review of systems (ROS)
Past, family, or social history (PFSH)
The extent of the history depends on the clinical judgment and the nature of the presenting problem.

16. Documentation of History
Fig. 4-6A
Using this sample, have students identify whether each piece of information is considered the chief complaint; a history of the present illness; past, family, and social histories; or a review of symptoms.

17. Documentation of History
Fig. 4-6B
Each history item identified in the medical record should be taken into consideration when filling out the History section of the review/audit form. Once all items are accounted for, elements for each history component can be determined. Based on these elements, the level of history can be determined.

18. 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)
See Figs. 4-8 through 4-11 for examples of a review/audit worksheet.

19. Lesson 4.2 Medical Records
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.

20. Medical Records (Cont’d)
Lesson 4.2
Medical Records (Cont’d)
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.

21. Documentation Terminology
E/M Terminology
New vs. Established
Consultation
Referral
Concurrent care
Continuity of care
Critical care
Emergency care
Counseling
Reimbursement for a consultation is significantly more than for an equivalent office visit.
What is “concurrent care?” (The provision of similar services [e.g., hospital visits] to the same patient by more than one physician on the same day)
What is “continuity of care”? (When a physician sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of the same condition)
Critical care usually takes place in the ED or a critical care unit of a hospital.

22. Documentation Terminology
New versus Established Patients
What is the difference between a new patient and an established patient? (A new patient has not received services from the physician [or a physician of the same specialty in the same practice] within the past 3 years. An established patient has received services from the physician [or a physician of the same specialty in the same practice] within the past 3 years.)
Use this decision tree (Fig. 4-12) to determine whether a patient is new or established.

23. 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
The AHA’s official policy is that “abbreviations should be totally eliminated from the more vital sections of the health record.” Many physicians are not aware of this policy and may continue to use abbreviations throughout the documentation.
What is an eponym? (The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it)
Define “acute” and “chronic.” (Acute: a condition that runs a short but relatively severe course. Chronic: a condition persisting over a longer period of time)
See Figure 4-14 for an example of some common medical abbreviations and symbols.

24. Directional Terms Fig. 4-14A
Have students name organs contained in each region. (RUQ: liver [right lobe], gallbladder, pancreas [part], small/large intestines [part]; LUQ: liver [left lobe], stomach, spleen, pancreas [part], small/large intestines [part]; RLQ: small/large intestines, right ovary, right uterine [Fallopian] tube, appendix, right ureter; LLQ: small/large intestines [part], left ovary, left uterine [Fallopian] tube, left ureter)

25. Directional Terms Fig. 4-14B
How do these nine regions relate to the four quadrants? (The nine regions are more specific and are part of the four quadrants.)

26. Surgical Terminology Preoperative vs. Postoperative
Simple/intermediate/complex
Undermining
Take down
Lysis of adhesions
Position
Approach
“Preoperative” is the period before a surgical procedure, and “postoperative” is the period after the surgical procedure.
Surgical procedures of the integumentary system are listed as simple, intermediate, or complex.
In a surgical report, explain what “undermining” means. (Cut in a horizontal fashion)
Define “take down.” (To take apart)
Explain what “lysis of adhesions” means. (Destruction of scar tissue)
Discuss why coders should care about position or approach in surgical reports. (Codes can be different depending on the position or approach documented in the surgical report.)
See Table 4-1 for ICD-10-PCS terminology used in coding procedures

27. Internal Reviews Prospective Retrospective Prebilling audit/review
Postbilling audit/review
Discuss why internal reviews are important to a medical practice. (Internal reviews may help prevent external audits and may catch errors before the billing cycle is complete. This will save the practice time, money, and possible penalties in the long run.)
Explain which type of internal review is done BEFORE billing and why. (Prospective review: Stage One—to verify that completed encounter forms match patients seen according to the appointment schedule and have been posted on the day sheet; Stage Two—to verify that all procedures or services and diagnoses listed on the encounter form match data on the insurance claim form)
Explain which type of internal review is done AFTER billing and why. (Retrospective review: to determine whether there is a lack of documentation)

28. 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
What is a facsimile? (Transmission of written or graphic matter by electronic means)
If not prohibited by state law, a fax is an acceptable method of communication regarding an insurance claim.
The cover sheet should indicate name of recipient, name of sender, date, total number of pages [including cover sheet], fax and telephone number of both parties, and a confidentiality statement.
Note dates/times of faxes in the medical record, similar to documenting telephone calls.

29. Faxing Documents Medical Document Fax Cover Sheet Fig. 4-18
The fax cover may have a section that should be faxed back to the sender, in order to confirm receipt of the fax by the intended recipient.

30. 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
What is a subpoena? (“Subpoena” means “under penalty.” It also refers to the writ that commands a witness to appear at a trial or other proceeding and give testimony.)
What is subpoena duces tecum? (Literally means “in his possession.” This is a subpoena that requires the appearance of a witness with his or her records.)
If needed for a trial, records must be kept secure. They should be mailed via certified mail (or other secure method) with return receipt.
Always comply fully with a subpoena or any instructions during a court proceeding.

31. Retention of Records Records Retention Schedule Table 4-2
How is a record retention schedule used? (Once records are kept for the appropriate amount of time, they can disposed of. This could mean shredded, conversion to microfilm, or disposal by a professional company.)
Are electronic health records on the same retention schedule as paper records? (Electronic health records may have different retention periods, depending on state law. Electronic files may also be easier to keep in the medical office, since they are easier to store.)
Discuss whether electronic medical records are more or less safe than paper records. (Electronic records can be more easily deleted and altered than paper records. Additional answers will vary.)

32. Termination of Case Example of a form letter Fig. 4-20
Explain when a physician might send this type of letter. (A physician may wish to withdraw formally from further care of a patient. This could be because of patient noncompliance, either in treatment or payment.)
Is this type of letter necessary? Explain why or why not. (This letter is necessary to prove the physician did not abandon the patient’s case.)

33. 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
Are these guidelines necessary? Explain why or why not. (Yes. An insurance billing specialist must be aware of legal issues in the medical practice and must follow guidelines to limit the likelihood of a lawsuit or external audit.)
See Box 4-1

34. 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
Ask students what the consequences would be if these guidelines were not considered. (External audit, sanctions, etc. Answers will vary.)
See Box 4-1

35. Questions?