Appropriately documented and signed medical records promote accurate coding, reduce claims processing time, and allow for accurate reimbursement. Below we identify some common issues found on medical records, and some quick fixes.
- Insufficient details about a condition. To help determine appropriate reimbursement in a timely fashion, your documentation should match the care provided and billed for, rather than simply identifying a condition via a diagnosis code. For example, instead of simply listing “asthma J45.20” in the problem list, it would be more appropriate to write “mild intermittent asthma – stable J45.20.”
- Missing signature. Make sure to sign and date the medical record, either electronically or by hand, with your credentials on each date of service, and obtain a co-signature if it is needed. The record is considered incomplete if it has not been signed.
- Not including a patient’s full name and date of birth. The patient’s full name and date of birth are required; including only a name and medical record number isn’t sufficient.
- Copying and pasting a problem list from a previous encounter. Doing this often leads to poor note quality, diagnoses that may no longer be relevant, or too much information — which can confuse another provider treating the patient.
Refer to future issues of Network Matters for more coding reminders and tips.