Back to Basics — Documentation 101 and Self-Auditing

Journey back to grade school grammar lessons for a moment and think of the interrogative pronouns: who, what, where, when, and why. Throw in “how many,” and you have a simple mnemonic to create exceptional documentation. 

  • Who — Performing, supervising, and referring practitioners  
  • What (and How Many) — Services and quantities of services performed  
  • Where — Place of service  
  • When — Date of service  
  • Why — Medical necessity and diagnosis  

These six items comprise a large part of the information Medicare requires to deem a service correct and payable. Documenting them thoughtfully is easy. 

The fundamental underpinnings for documenting and reporting services to Medicare are that every item of information reported on the claim (electronic or paper) must be true and accurate, and it must be reflected in the patient’s medical record. This isn’t news. You have heard or read this statement possibly hundreds of times. But have you actually audited your own records to measure how often your records do or don’t measure up? 


Need Help Auditing Your Charts?

 Learn about self-audits, what to do with your findings, and how to get buy-in for corrective actions, in TMA's on-demand webinar, Avoiding RAC Audits. In addition, TMA offers the following coding and documentation services exclusively to TMA members: 

  • Comprehensive chart audits: A comprehensive analysis of your practice’s coding and documentation habits presented in a written report with findings and recommendations for improvement.  
  • Coding and documentation check-ups: An abbreviated review of claims coding and medical record documentation performed to provide a glimpse into a physician’s coding techniques and habits.  
  • Customized staff training: Training for physicians and staff — customized to your practice — on documentation guidelines, inappropriate or inaccurate coding, and weaknesses in medical record documentation that may expose the practice to problems with payers (qualifies for continuing medical education credit).  

 To schedule your audit, contact TMA Practice Consulting at (800) 523-8776 or[at]texmed[dot]org . 

Last Updated On

June 01, 2016

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Audits | Coding | Medicare | Practice Consulting