August 2009
Medicare medical record reviews and documentation tips
Medical record reviews continue
We recently began reviewing medical records to support compliance with Medicare standards. These reviews will continue through the fall. Regence and Secure Document Imaging, LLC staff are contacting offices to collect data using Health Insurance Portability and Accountability Act (HIPAA)-compliant processes.
Participation in this quality assurance and improvement activity is a contract requirement for Regence MedAdvantage physicians, other health care professionals and facilities. Your cooperation during this data collection period is appreciated.
Documentation and coding tips
The following tips can help ensure accurate medical coding and billing compliance, based on current Centers for Medicare & Medicaid Services (CMS) requirements for Medicare Advantage plans.
- Include a legible identifier (name and credentials of provider) for services rendered/ordered:
- The method used must be hand-written or an electronic signature to authenticate an order or other medical record documentation. Rubber stamp signatures are not acceptable.
- Initials are acceptable only if the full name and credentials of the provider appear elsewhere in the record (e.g., in the letterhead on which the documentation is recorded or on a signature log, which can be produced upon request).
- Record the patient's name and date of service on each page of documentation.
- Evaluate the status of each active diagnosis (including chronic conditions) on the patient's problem list, and update the progress notes accordingly. The problem list alone is not reportable documentation.
- Report chronic conditions at least once each calendar year, preferably at the patient's annual physical. These conditions may not have been routinely submitted on claim forms as a secondary diagnosis (e.g., history of myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, complications of diabetes).
- Include information in the patient's progress note to reflect all over-the-counter or prescription medications that are being actively managed or assessed on that date of service for each acute and/or chronic condition (e.g., "DM well controlled - taking Metformin," "Atrial fib stable - on Coumadin as directed").
- Include an accurate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code selection, including the fourth and fifth digits, when required. See the related online article, The importance of accurate diagnostic coding, for more information.
- Include the maximum number of codes allowed per submission.
- Look for documentation and include coding from physician reporting of chronic conditions. These conditions may not have been previously or routinely submitted on claim forms as a secondary diagnosis (e.g., history of myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, complications of diabetes).