The point of a medical record is to enable safe, accurate, and thorough care for your patient. For insurance reimbursement, medical documentation needs to show adequate support for all services provided to the patients in your care. If the insurer cannot find any of the following within your medical documentation, your practice may be at risk for claim denials, appeal denials, insurance payment deductions, and possibly even insurance audits. All patient medical records should include but are not limited to:
Illegible medical documentation can cause confusion and injury for the patient as well as be considered incomplete and discredited among your patient’s insurer. We know each practice runs on a time-consuming schedule. If your signature cannot be identified, this alone could cost you more time supplying explanations and further resubmissions later on. It is recommended to keep a letter of each doctor’s signature verification on file to submit with documentation, and to update your signature logs annually. If you are already including each of the above, do not forget to make sure each factor is legible. Secure EMR systems are now available to reduce illegible record keeping.
Medical records are reviewed for a number of reasons. Medical claims are randomly selected for audit by insurers. They are required and reviewed during each request for a claim appeal whether submitted by your office or the patient themselves. An insurer may question the medical necessity and request the records of their own accord for review. With MIPS in full gear, one of the measures utilized for incentive review is that of medical documentation.
Taken directly from a reviewer at a Medicare contractor, “While a form is nice for making sure you have completed all necessary sections of the record, it does not always clearly explain why steps are taken/services are rendered/orders are requested. Your medical record should paint a picture, it should tell a story, and it should be as detailed as you can make it.”
There are a number of webinars and seminars that can help you as well. We found this one in particular through WPS to be highly informative in regards to documentation requirements. Another seminar is being held next month.
However you look at it, your documentation should be thorough, reviewed and updated each time a patient is seen. Your office should have an individual record for each patient. Records should be kept through an organized, systematic, and secure method. Each record should be easily accessible each time they are required for review while identifiably describing each factor listed above.