An appropriately documented medical record can reduce many of the hassles associated with processing claims for evaluation and management (E&M) and other services. Following is a list of principles to guide you in documenting E&M services:
- Current procedural terminology and ICD-9 codes reported on the insurance claim or billing statement must correspond with the documentation in the medical record.
- For each visit, the physician must document the chief complaint or reason for the visit, relevant history, physical examination findings, prior diagnostic test results, assessment, clinical impression or diagnosis, plan for care, date of visit, and the name of the health care professional who provided the service.
- The physician must document the rationale for ordering diagnostic or other ancillary services; if not, the rationale should be easily inferred.
- The medical record should be complete and legible.
- An addendum to the medical record should be dated the day the information is added to the medical record, not the date the service was provided.
- Physicians should document the visit as it is happening, or shortly thereafter. Delayed entries within a reasonable time frame - 24 to 48 hours - are acceptable when you are clarifying information, correcting an error, or adding new information not initially available, or if unusual circumstances prevented you from including the note at the time of service.
Still confused about correct coding and documentation? TMA Practice Consulting can help by conducting a coding and documentation review of your practice. TMA's experienced consultants will analyze a representative sample of your practice's patient charts and corresponding explanations of benefits, claims, and fees; identify problem areas; make recommendations for improvement; and provide on-site training in correct procedures. An annual coding and documentation review will help ensure that your practice is receiving proper payment for your services.
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