Why Documentation
Medical documentation has been found in ancient Egyptian records that
contained details of surgical procedures and the medication used to heal
patients (Grider, 2015). The need to pass on the how and what of
procedures and the art of healing have been practiced by individual
providers through written and oral recordings throughout history. How it
was passed from one to another is as important as what information was
passed from one person or generation to the next. This is where the medical
documentation that the field uses today started its transformation. The
medical record has transformed from a source to keep medical histories, to
a source used to track health statistics through the use of the International
Classification of Diseases (ICD) codes, to a document to be used by the
provider to justify payments received for services rendered, to a legal
document to both defend and accuse a medical provider and to evaluate the
quality of care provided to a patient (Brodnik, Rinehart-Thompson, &
Reynolds, 2012).
Medical coding encompasses the entire medical chart. It is used primarily to
describe the patient’s medical condition. It is also used to submit
information to the insurance company for payment of services, and to
submit information for research. The medical coding in the chart represents
a person’s entire medical history; for this reason, it must be accurate and
complete. Before a chart can be coded, there must be a chart.
As students will explore in Module One, the medical chart is a detailed
record of a patient’s encounter with the medical professional. The
encounter could happen in a physician’s office, in an outpatient setting of a
hospital, or as an inpatient in an acute care facility or in a variety of other
locations. The medical record is indispensable for the patient’s care.
Without a place to document the care provided to the patient, there would
be no evidence of what has or has not been done. This can put both the
patient and the medical provider at a tremendous risk.
The medical chart is comprised of two different types of documentation.
The first is non-clinical or administrative information. This information
refers to items such as the patient’s name, address, date of birth, and
insurance information. This is also referred to as the patient demographics.
The second part of the chart, which is the part students will be studying in
the course, is the medical documentation. This contains items such as the
problem list, the patient’s medication list, the physical condition of the
patient, the information gained at the patient’s visit, results of testing such
as lab and x-ray, and information on the decisions made by the medical
provider. This documentation, depending on the type of facility, can be used
by many providers or it can be used by just the providers in one clinic. How
many providers use the information is not the important part of the
documentation. What is important is completeness and accuracy of the
information in the chart. This is the area in which the compliance
department will focus the majority of its attention.
A normal compliance plan will require annual medical record auditing and
monitoring. The audit is generally conducted once per year for evaluation
and management codes. If the provider maintains a 95% coding accuracy,
then the charts should not require auditing again for another year. The 95%
coding accuracy is the allowed accuracy specified by the Office of Inspector
General (OIG) for medical providers (Grider, 2015). Performing an annual
audit helps to ensure that the medical documentation meets the guidelines
developed by the organization, and verifies that the documentation meets
payer regulations as well as coding guidelines. This audit will provide the
compliance department with valuable information to determine educational
needs for the providers; it will indicate areas in which the work flow may
need improving, and it will help the organization to determine valuable
updates which may be needed to improve efficiency in the healthcare
provider’s office.
Just as there are different types of healthcare locations—such as inpatient
facilities, healthcare clinics, and home health offices—there are also different
ways of monitoring claims payments. Some types of claims are typically paid
first and could be audited afterward. This is known as a post-payment audit.
There are also claims that are audited first and then paid—hence, a pre-
payment audit. In both cases, the payer is looking at the documentation for
the encounter to determine if the billed code is supported by the
documentation found in the chart. Part of the auditing and/or monitoring
process is called the clinical documentation improvement (CDI) process.
This process is generally used in the acute care hospital setting, but it can be
used in any healthcare location because documentation is found in all
healthcare encounters. Reaching the OIG’s accuracy rate of 95% is the
primary goal of the CDI process. Developing the CDI process will require a
variety of steps, including determining the accuracy rate of providers,
developing a process to query providers if a chart is found with non-
supporting documentation, and educating providers about documentation
requirements. This is not a one-time process, but a continuing process
requiring monitoring and education as a regular process for the facility.
Students explore the importance of chart documentation and the auditing
process in this module. In Module Two, students will use this information to
explore the use of electronic health records. Students will examine charts to
determine if the providers are using the electronic health records program
to appropriately document and supply the needed information to properly
code and bill for the services performed.
References
Brodnik, M. S., Rinehart-Thompson, L. A., & Reynolds, R. B.
(2012). Fundamentals of law for health
informatics and information management (2nd ed.). Chicago, IL: American
Health Information Management Association.
Grider, D. J. (2015). Medical record auditor (4th ed.). Chicago, IL: American
Medical Association.
