The trusted source for
healthcare information and
The best way to avoid payment and audit questions about your billing procedures is to make your claims are fully documented. Make sure, for instance, that:
• The medical record is complete and legible.
• Documentation of each patient encounter includes or references: the chief complaint and/or reason for the encounter and, as appropriate, relevant history, examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the health care professional.
• If not specifically documented, the reason for the encounter and/or chief complaint and the reason for ordering diagnostic and other ancillary services can be easily inferred.
• Past and present diagnoses and conditions, including those in the prenatal and intrapartum period that affect the newborn, are accessible to the treating and/or consulting physician.
• Appropriate health risk factors have been identified.
• The patient’s progress, response to and changes in treatment, planned follow-up care, and instructions and diagnosis are properly documented.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement are supported by the documentation.