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2014-12-01. The Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.3, “Third-Party Additional Documentation Request” states: The treating physician, another clinician, provider, or supplier should submit the requested. Additionally, another thing that makes it difficult to determine is that to arrive at a particular level, providers and coders have to consider four categories, and within the table there are four corresponding types. OBJECTIVES To ensure clinical documentation within the Alberta Health Services’ (AHS) clinical record, a subset of the health record, supports health care providers in the delivery of high-quality patient care, strengthens patient safety, and promotes continuity of care. Medical Documentation Guidelines. The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. documentation practice, these documentation guidelines encourage employers, medical record and clinical staff to incorporate strategies, policies and procedures that strengthen effective documentation practices within the work setting. by Diana Williams, BS, CPC, CPMA, CCS-P, CCS There are many concerns for providers and coders when it comes to medical decision making, especially when Medicare’s Documentation Guidelines for Evaluation and Management Services are more striking for what they leave unsaid. CMS provides guidelines to help ensure every patient’s health record contains quality documentation. Strategies to maintain quality documentation practice include; Organisational Support Documentation guideline: The initiation of, or changes in, treatment should be documented. CPT® and ICD-9-CM codes reported on health insurance claim forms should be supported by documentation in the medical record. Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented. 100-02, Chapter 2, Section 30 Documentation guideline: If a diagnostic service (test or procedure) is ordered, planned, scheduled or performed at the time of the E/M encounter, the type of service (e.g., lab or X-ray), should be documented. Do not alter existing documentation or withhold elements of a medical record once a claim emerges. Documentation Guidelines. • The medical record documents the care of the patient and is an important element contributing to high quality care. You can reach her at Diana.Williams@FTIConsulting.com. Set Forth the Basics of Good Medical Record Documentation, Change Request (CR) 2520, Provider Education Article, Medicare Benefit Policy Manual, Pub. CMS Internet-only Manual (IOM), Pub. It’s always best to examine your daily routines periodically. ISSN 1931-3209 (online). To qualify for a level of MDM, the highest two of three elements must be met. Medical Documentation Guidelines. MLN Matters® SE1237: Importance of Preparing/Maintaining Legible Medical Records For every service billed, a provider must indicate the specific sign, symptom, or patient complaint necessitating the service. General principles of medical record documentation for reporting medical and surgical services for Medicare payment include (when applicable to the specific setting/encounter): Medical records should be complete and legible. Identify documentation practices that create legal and professional risks. For any disability or condition which impacts physical well-being, such as, but not limited to: impaired vision, impaired hearing, impaired mobility, diabetes, Crohn’s Disease, etc., the student is required to provide documentation of the disability/condition. Medical records are a crucial form of communication. All rights reserved. Clearly and permanently identify an amendment, correction, or delayed entry, as such. Medical documentation must be provided by a licensed health care professional who has appropriate and comprehensive training, relevant experience, and no personal relationship with the individual being evaluated. Documentation should be prepared on letterhead, typed, dated, and bear the signature of the evaluator. Social Security Act, Section 1862(a)(1)(A) She holds a Bachelor of Science degree in Media Communications - Journalism. Post was not sent - check your email addresses! It is essential for good clinical communication and a core requirement of the Nursing Council of New Zealand Practitioners are expected to complete the documentation of services during or as soon as practicable after it is provided to maintain an accurate medical record. Specific information is available according to the type of disability. Include date of onset as well as treatment dates. Please make sure to reference the set of guidelines that most closely match the student’s disability. Date. Documentation guideline: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented. Understand Documentation from a Risk Perspective, Use CMS’ General Principles to Improve Documentation, A provider’s ability to evaluate and plan the patient’s immediate treatment and to monitor his or her healthcare over time, Communication and continuity of care among providers involved in the patient’s care, Accurate and timely claims review and payment, Appropriate utilization review and quality of care evaluations, Data collection that may be useful for research and education. Until the practitioner completes the documentation for a service, including the signature, the claim cannot be submitted to Medicare. 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