Your Medical Documentation Matters - CMS
12/9/2015
Your Medical Documentation Matters
Presentation
Objectives
At the conclusion of this presentation, participants will be able to:
? Identify Medicaid medical documentation rules
? Explain that services rendered must be well documented
and that documentation lays the foundation for all coding
and billing
? Describe the national impact of improper payments
Centers for Medicare & Medicaid Services
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Goals
? The participant will become familiar with Medicaid medical
documentation rules
? The participant will discover through a case study the
importance of complete and detailed documentation as the
foundation for coding, billing, and quality of care for the
patient
? The participant will learn how insufficient documentation
leads to both poor patient care and to improper payments,
which have a negative national impact on Medicaid
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12/9/2015
Medicaid Is Unique
? States have the flexibility of tailoring their Medicaid programs.
? It is the medical professional¡¯s responsibility to know and
adhere to all Medicaid rules
? If there are questions, contact your State Medicaid agency
(SMA) at
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Progressive Case Study
Meet J.K.
J.K. is:
? 52 years old
? Male
? 265 pounds
? Married
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Medical Professionals and
Documentation
Documentation is an important aspect of patient care and is
used to:
? Coordinate services among medical professionals
? Furnish sufficient services
? Improve patient care
? Comply with regulations
? Support claims billed
? Reduce improper payments
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Purpose of Electronic Health Records
The purpose of electronic health records (EHRs) is to
improve health care:
? Quality
? Safety
? Efficiency
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General Principles of Medical
Record Documentation
General principles of documentation include:
? The medical record should be complete and legible
? The documentation of each patient encounter should
include the:
o Reason for the encounter and relevant history, physical
examination findings, and prior diagnostic results
o Assessment, clinical impression, or diagnosis
o Medical plan of care
o Date and legible identity of the observer
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General Principles of Medical Record
Documentation¡ªContinued
Document the:
? Rationale for ordering diagnostic and other ancillary
services
? Past and present diagnoses
? Health risk factors
? Patient progress, treatment changes, and response
? Diagnosis and treatment codes reported on the health
insurance claim form or billing statement
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12/9/2015
Emergency Services¡ªAmbulance
J.K. is transported by ambulance to the nearest hospital
emergency department (ED). During transport, a brief
history was taken, including his:
? Chief complaint (C.C.)
? Vital signs
? Current medications
? Medical ambulance need
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Emergency Transportation
Documentation¡ªDriver/EMT
At a minimum, document the:
? Patient¡¯s identifying information
? Requester¡¯s name and address
? Date of transport
? Location pickup and time
? Location drop-off and time
? Loaded mileage
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Emergency Transportation
Documentation¡ªState-Specific
Know your State-specific documentation expectations, such as:
? Pre-Hospital Care Report
? Dispatcher¡¯s log
? Trip ticket
? Ambulance Run Report
? Medical need for the ambulance
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Documentation¡ªLacking
The missing documentation included:
? Medical necessity documentation
? A Physician Certification Statement
? Required signatures
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Documentation¡ªLegible
Medicaid medical records should be legible. At a minimum,
a medical record should be:
? Written so it can be read
? Written in ink
? Written in clear language
? Written without alterations
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Clarity in EHR
? Specific to patient
o Avoid ¡°cloning,¡± auto-fill, or key word features
o Document patient¡¯s description
o Include clinical notes for visit
?
?
Update patient history and life events
Check spelling and acronym usage
o Turn off autocorrect spelling (might change acronyms
to words)
o Clearly separate individual notes with punctuation,
spacing, or paragraph returns
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