Documentation requirements extend beyond Medicare

Coverage and reimbursement rules may differ, but documentation requirements do not.

Issue: November 1, 2003

ByDonna McCune, CCS-P, COE

Issue

A 2-year-old child is presented for an eye examination. Her mother is concerned that the child may need glasses, as she frequently squints. The child is uncooperative, and the examination is difficult. The ophthalmologist makes minimal chart notes and the chart is sent to the billing office to be filed as a comprehensive eye examination (code 92004).

Before submitting the claim to the third-party payer, the billing office reviews the chart notes and informs the physician that the documentation supports a level 1 E/M code (99201). The mother completed the registration form but ignored the history form. The exam notes state that the patient “fixates and follows,” and her pupil size appears normal. The physician writes, “Deferred for intraocular pressure.” There are no further chart notes. His assessment is normal eye exam.

“This isn’t Medicare, so I don’t have to comply with all those rules,” the physician responds to his staff member.

Do the documentation guidelines extend beyond Medicare?

The basic principles of chart documentation extend beyond Medicare and apply to all types of medical and surgical services.

The medical record should be complete and legible. Each encounter should include: date of service, subjective complaint, history relevant to the complaint, exam findings, assessment, treatment plan and legible identity of provider (ie, signature).

The selection of the appropriate level of service is based on the documentation of these basic elements. The existence or type of third-party payer has no bearing when considering the need for these basic documentation requirements.

The patient’s medical record validates the appropriateness of the services provided. Also, it is the basis for coding and billing by verifying that the services were performed, validating where they were performed and describing the extent of services.

Documented notations may vary when certain circumstances are present. An exam element may be considered performed if it is deferred because it is medically contraindicated, rather than overlooked or postponed due to patient preference. For example, dilation may be contraindicated if the patient presents with narrow anterior chamber angles. A notation is made to reflect the absence of dilation and the medical contraindication. Leaving an exam element blank means it was ignored and no credit is given.

The examination of a child, as referenced in the case study, is another example in which traditional documentation of the elements may not be possible. For example, the slit-lamp exam may be performed using a penlight if the child is unable to sit still behind the slit lamp. Chart notation for the anterior chamber and lens might read “grossly normal w/penlight.” Once again, the absence of a notation implies that the element was not examined.

Documentation guidelines extend beyond Medicare, and the threat of a postpayment review exists with any payer. Furthermore, the need for thorough documentation extends beyond reimbursement. The medical record serves as a tool for treating the patient and as a means to communicate the patient’s care to others.