Basics of Medical Documentation and Medicare
Documentation and Medicare
The aim of medical documentation is to ensure that Medicare dollars are administered correctly and, once again, medical documentation must support the medical necessity of the service, to what extent the service was rendered, and why it was medically justified. For example, based on findings from a routine x-ray exam, a radiologist may believe further studies are warranted. Documentation must indicate the medical necessity for the added studies. In such a situation, the radiologist is not required to check with the ordering physician before proceeding. However, the service may require prior authorization from the payer, depending on payer guidelines.
Medicare does not pay for services that are ‘medically unnecessary,’ according to Medicare standards. Patients are not liable to pay for such services if the service is performed without prior notification from the physician. Medical necessity requires items and services to be:
- Consistent with symptoms or diagnosis of disease or injury
- Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational)
- Furnished at the most appropriate level that can be provided safely and effectively to the patient
Methods of Documentation
Problem-Oriented Medical Record (POMR)
- In problem-oriented medical record (POMR), the provider identifies problems individually and arranges them for resolution. The POMR has four elements Database, Problem list, Initial plans, and Progress notes.
- At a minimum, the data portion of the POMR includes information such as chief complaint, present illness, past, present, family, and social history, review of systems, physical examination, and baseline ancillary data. The problem list consists of any problem that requires management or diagnostic workup. It may be a symptom, an abnormal finding, a physiological finding, or a specific diagnosis. The provider adds or changes the list as problems are identified and resolved.
- The third portion, initial plans, states what the provider plans to do to learn more about the problem, to treat it, and to educate the patient about the problem. Progress notes are the final element of the POMR. Each problem is documented with regard to the following: (S)ubjective findings (symptoms); (O)bjective findings (measurable, observable); (A)ssessment (interpretation or impression of the current condition); and (P)lan (treatment). This process is often referred to by the acronym “SOAP.”
Integrated Medical Record
- The integrated medical record is another method of documentation that is strictly chronological without section divisions by the source of care. This keeps the episode of care documented in one continuous flow by date; but may make it more difficult to compare information from the same source, such as laboratory data. Because of this disadvantage, some chart order arrangements may integrate certain types of forms while maintaining others, such as radiology reports, together chronologically.
- No specific format for documentation is recommended. It depends on the provider. But it is important that anyone reading the medical record be able to understand from the documentation the service rendered and the reason for the service.
General Guidelines for Documentation
Documentation is the recording of pertinent facts and observations about a patient’s health history, including past and present illnesses, tests, treatments, and outcomes. The medical record documents the care of the patient to:
- Enable a physician or other health care professionals to plan and evaluate the patient’s treatment
- Enhance communication and promote continuity of care among physicians and other health care professionals involved in the patient’s care
- Facilitate claims review and payment
- Assist in utilization review and quality of care evaluations
- Reduce hassles related to medical review
- Provide clinical data for research and education
- Serve as a legal document to verify the care provided (e.g., as a defense in the case of a professional liability claim)
To ensure the appropriate reimbursement for services, the provider should use documentation to demonstrate compliance with any third-party payer utilization guidelines.
Principles of Documentation
To provide a basis for maintaining adequate medical record information, follow the principles of medical record documentation listed. The principles below have been developed by representatives of the following organizations:
- American Health Information Management Association (AHIMA)
- American Hospital Association (AHA)
- American Managed Care and Review Association (AMCRA)
- American Medical Association (AMA)
- American Medical Peer Review Association (AMPRA)
- Blue Cross and Blue Shield Association
- Health Insurance Association of America (HIAA)
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