Chapter 04 Medical Documentation and the Electronic Health Record

1. Insurance Handbook for the Medical Office 13th edition Chapter 04 Medical Documentation and the Electronic Health Record

2. Documentation Basics Identify the most common documents founds in the medical record. List the advantages and disadvantages of an electronic health record. Describe the incentive programs established through federal legislation for adoption of electronic health records in physician offices and hospitals. Define meaningful use and compare the implementation stages. Lesson 4.1

3. Documentation Basics (cont’d) Define the various titles of physicians, as they related to health record documentation. Explain the reasons that legible documentation is required. List the documentation guidelines for medical services. Identify the components required for documentation of an evaluation and management service based on 1997 Medicare guidelines. Lesson 4.1

4. The Documentation Process Documentation is “a chronologic detailed recording of pertinent facts and observations about a patient’s health as seen in chart notes and medical reports.”

5. The Documentation Process • Common medical office documents • Patient registration (demographic information) • Medication record • History and physical examination notes or report • Progress or chart notes • Consultation reports • Imaging and x-ray reports • Laboratory reports • Immunization record • Consent and authorization forms • Operative report • Pathology report

6. Health Record Systems • Problem-oriented record system • Documents are flow sheets, charts, graphs • Source-oriented record system • Documents stored in sections • Electronic health record system • Collection of medical information about a patient • Difference between EHR and EMR

7. Electronic Health Records • Advantages of the EHR • Less physical space required • Automatic data capture • Available data for other purposes • Easier authentication • Automatic insurance verification • Automated/computer-assisted coding • Batch transmittal of insurance claims • Complete online management

8. Incentive Programs for Adoption of Electronic Health Records Physician Quality Reporting System Incentive Program E-Prescribing Incentive Program Electronic Health Record Incentive Program Meaningful Use

9. Meaningful Use • Stage 1: 2011-2012 • Focused on data capture and sharing • Stage 2: 2013 • Focused on advance clinical processes • Stage 3: 2015 • Focuses on improved outcomes

10. Documenters • Types of Physicians • Attending physician • Consulting physician • Non-physician practitioner (NPP) • Ordering physician • Primary care physician (PCP) • Referring physician • Resident physician • Teaching physician • Treating or performing physician

11. Legible Documentation Avoidance of denied or delayed payments by insurance carriers investigating the medical necessity of services Enforcement of medical record-keeping rules by insurance carriers requiring accurate documentation that supports procedure and diagnostic codes Subpoena of medical records by state investigators or the court for review Defense of a professional liability claim Execution of the physician’s written instructions by a patient’s caregiver

12. Legalities of Health Record Billing Patterns • Billing Patterns Causing Possible Audit • Billing intentionally for unnecessary services • Billing incorrectly for services of physician extenders • Billing for diagnostic tests without a separate report in the medical record • Changing dates of service on insurance claims to comply with policy coverage dates • Waiving copayments or deductibles, or allowing other illegal discounts

13. Legalities of Health Record Billing Patters • Billing Patterns Causing Possible Audit (cont’d) • Ordering excessive diagnostic tests • Using two different provider names to bill the same service for the same patient • Misusing provider identification numbers, resulting in incorrect billing • Using improper modifiers for financial gain • Failing to return overpayments made by the Medicare program

14. Documentation Guidelines for Medical Services

15. Documentation of History Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) Past, family, or social history (PFSH)

16. Documentation of History

17. Documentation of History

18. Documentation of Examination • Physical examination • Organs systems/body areas – elements of examination • Types of physical examination • Problem focused (PF) • Expanded problem focused (EPF) • Detailed (D) • Comprehensive (C)

19. Medical Records Define common terminology related to medical, diagnostic and surgical services. Abstract information from the medical record to complete a life insurance application. Describe the difference between prospective and retrospective review of records. Lesson 4.2

20. Medical Records (Cont’d) List examples of documents containing sensitive information that should not be faxed. Respond appropriately to the subpoena of a witness and records. Identify principles for retention of health records. Formulate a procedure for termination of a case. Lesson 4.2

21. Documentation Terminology • E/M Terminology • New vs. Established • Consultation • Referral • Concurrent care • Continuity of care • Critical care • Emergency care • Counseling

22. Documentation Terminology New versus Established Patients

23. Diagnostic Terminology and Abbreviations Most physicians use abbreviations in medical documentation Eponyms should not be used if another medical term applies Proper documentation guidelines should always be followed Documentation should be as specific as possible

24. Directional Terms

25. Directional Terms

26. Surgical Terminology Preoperative vs. Postoperative Simple/intermediate/complex Undermining Take down Lysis of adhesions Position Approach

27. Internal Reviews • Prospective • Prebilling audit/review • Retrospective • Postbilling audit/review

28. Faxing Documents “Fax” is derived from “facsimile” State law may prohibit transmitting claim information via fax Sensitive information should have a cover sheet Confirm the fax arrived at the destination Never fax financial information Consult an attorney regarding the faxing of legal documents

29. Faxing Documents Medical Document Fax Cover Sheet

30. Subpoena Process Issued by a judge to obtain witness statements or records May not require an appearance in person Never accept a subpoena or give records without the physician’s prior authorization

31. Retention of Records Records Retention Schedule

32. Termination of Case Example of a form letter

33. Prevention of Legal Problems Keep patient information confidential Report all physician activity which is illegal or unethical Be aware of any hazards which may cause injury Do not discuss other physicians with patients Take the time to explain fees to patients

34. Prevention of Legal Problems Be sure documentation corresponds with insurance billing Be aware of all changes in insurance program guidelines Always obtain written consent for records release Obtain physician authorization before turning an account over for collection Always act in a courteous and professional manner

35. Questions?