Introduction

DOCUMENTATION GUIDELINES

              FOR EVALUATION AND MANAGEMENT SERVICES

I.            INTRODUCTION

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care.  The medical record facilitates:

·            the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time.

·            communication and continuity of care among physicians and other health care professionals involved in the patient's care;

·            accurate and timely claims review and payment;

·            appropriate utilization review and quality of care evaluations; and

·            collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided.  They may request information to validate:

·            the site of service;

·            the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or

·            that services provided have been accurately reported.