Accurate patient record documentation requirements hopes to "foster quality and continuity of care." Additionally, medical record standards target improved lines of communication between providers, patients and providers, along with provider to payer communications.
While payers establish their own expectations, all expect accurate evidence-based documentation, preferably electronic. Payers, including Medicare and Medicaid, develop their own checklists, but most requirements include the following items.
Typical Payer Documentation Expectations
Patient medical records should always include the following data.
- Clear identification of patients on each document component.
- If kept in "paper" files, legible entries in high contrast ink, preferably black or dark blue, on all documentation to minimize reader error.
- All recorded entries should be clearly dated and authenticated by the provider.
- Use accurate codes, supported by equally thorough documentation.
- Employ on common (standard) medical abbreviations, eliminating misunderstandings in translation or entry.
- Include every patient "encounter," including phone, fax and electronic messages.
- Clear recording of problems, medical conditions, medications, allergies, physical exams, immunizations, lab and diagnostic test results, diagnosis factors and treatment plans.
Payers will complete periodic document reviews, to evaluate the accuracy, clarity and thoroughness of submitted provider documentation. Claim delays and/or denials may result if documentation does not achieve, at least minimum payer standards.
Providers and their billing staff are cautioned to pay particular attention to the new coding system, as simple "typos" will typically cause reimbursement delays, at a minimum. Correcting an unjust claim denial because of deficient documentation is more difficult and time consuming than submitting it accurately initially.
Combine Quality Care with Cost Control
Healthcare reform demands delivering quality care, while employing new mandates, including more detailed documentation, seamlessly for maximum patient and provider benefit. Optimizing clinical documentation is a key to maintaining revenues. But, will it affect quality patient care?
The new requirements for "meaningful use" justification, pay-for-performance plans and ICD-10 codes are daunting changes in documentation, but should not result in lower quality care. Providers should find ways to lower and control costs, while maintaining their level of patient care.
Capturing and reporting accurate information has never been more critical to generating revenue, claims submission and patient communications. Medical providers should evaluate the cost management advantages of outsourcing some functions to leading billing, coding and documentation firms, such as M-Scribe Technologies, to remove much of the pressure to improve patient care while also tightly controlling expenses.
Practice staff under additional pressure face major performance challenges. Is it really wise to subject possibly maxed-out personnel to increased pressure of additional, unfamiliar documentation requirements? Probably not.
Similarly, is there any wisdom in medical providers in putting this extra pressure on themselves to lower and control costs, while improving patient care? The answer is easy: No. The bottom line remains the delivery of quality care. The rest of a successful bottom line financial equation will follow.
Increased documentation should not negatively impact quality patient care. Although there is a natural learning curve with any new policies, procedures and requirements, the negative implications can--and must--be minimized. How this goal is reached is typically up to the provider and/or the practice.
However, medical providers will rue the consequences of allowing new documentation necessities to interfere with quality patient care delivery. Even if the immediate concerns are maintaining strong revenue and lowering expenses, delivering quality care will become much more vital in the longer term.
Practitioners delivering consistent, quality care will eventually eliminate the potential negatives in complying with documentation and communication requirements. Just as new coding and digitizing patient medical records is challenging, the future should eliminate these fears, as more providers and practices become comfortable with these realities.
The future health of your patients and practice depends on marrying quality care with cost control and creating clear, accurate documentation. Is this a challenge? Yes. Is it possible? Also, yes.