Physician's Coding Strategist: What the OIG wants on all proper bills

While it is the provider’s responsibility to document each case, coders need to screen each claim carefully to ensure it is thoroughly and properly documented to speed the payment process and prevent queries from investigators. Here’s a checklist of items that the Office of Inspector General says every properly documented claim should be able to reference:

  • reason for the patient encounter;
  • appropriate history and evaluation;
  • documentation of all services;
  • documentation of the reason for all services;
  • ongoing assessment of the patient’s condition;
  • information on the patient’s progress and treatment outcome;
  • documented treatment plan;
  • plan of care, including treatment, medication (including dosage and frequency), referrals and consultations, patient and family education, and follow-up care;
  • changes in the treatment plan;
  • documentation of the medical rationale for the services;
  • documentation that supports the standards of medical necessity, such as certificates of medical necessity for durable medical equipment, prosthetics, orthotics, supplies, and home health services;
  • abnormal test results addressed in documentation;
  • identification of relevant health risk factors;
  • documentation that supports the evaluation and management codes that are billed;
  • medical records that are dated and authenticated;
  • prescriptions.