Do you want to save your practice time and money? Here’s a tip: Stay on top of documenting your patients’ records.
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Explore This IssueDecember 2009
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Physicians have a duty to ensure that all treatment records accurately reflect the treatment or services rendered. Corrections or changes to entries may be made only where the change is clearly identified as such, dated, and initialed by the person making the change. In fact, it is against the law to alter medical records with the intent to deceive or mislead anyone.
Medicare typically expects documentation of a medical service to be recorded at the time of service or shortly thereafter. Delays of 24 to 48 hours are acceptable in cases where clarification or an error correction is needed or if the additional information was not available at the time the documentation was done.
The longer a physician waits to do his or her dictation and complete the documentation, the greater the chance for inaccurate reporting. Some physicians find themselves trying to remember what was actually done. They may rely on past dealings with a patient or past visits with a similar patient, which could possibly lead to having cloned notes. Cloned notes can be found in two forms: when all of an individual patient’s visits are worded the exact same way in the medical record or when different patients’ medical charts have the same or similar documentation.
Physicians often get so bogged down with the day-to-day activities of running their practices that they delay completing the documentation of patients’ visits. Do not fall into the trap of thinking that you must have done a certain step in a visit because that is how you usually do it. Not every patient is treated the same way. Even patients with the same diagnosis can require you to alter how you perform your visit with that particular patient. Delays in completing the documentation of medical records can lead to delays in submitting the claim to the Centers for Medicare and Medicaid Services (CMS) or an insurance carrier. If a physician waits to complete the medical record for a patient, he or she could forget some or all of the pertinent information concerning that specific visit. For example, one might forget the exact reason for a lab that needs to be ordered or the results of a bone mineral density scan. Without this information, the coder cannot accurately determine what level of visit this would be. Remember, if something is not documented, it is not billable. Accurate and timely documentation is the combination needed to correctly record the patient’s visit. This will always put you on the right path for coding the proper level of patient’s visits, which will ultimately save you time and money.