Module Lecture

The Standards for Healthcare Records

The healthcare world is not a provider on an island where there are no

concerns for the information in the records beyond the borders of the

island. There are numerous amounts of information that must be

documented correctly and within some very strict and exacting guidelines.

The number of entities that set the regulations for the information found in

the charts seems to grow each year. The medical data found in the charts is

no longer just for the care of the patient; it is now used to measure the

quality of patient care and to determine how compliant the provider is in

and the diagnoses of the issues that brought the patient to the provider’s

office. The medical chart is coded by a staff member or the medical staff.

These codes are then transferred to the patient’s insurance carrier for

payment of the services. The payer processes the claim submission and then

sends payment back to the healthcare provider. This is when the borders of

the island begin to fade.

There are several agencies that influence the formatting of the

documentation found in the medical chart. The guidelines for coding the

procedures that represent the services received by the patient are written

by the American Medical Association (AMA) and adopted by the Centers for

found in the medical charts as accurate and supportive of the services for

which the medical provider has received payment. This same principle

applies to all areas of the government when it comes to using taxpayer

money to pay an entity for services rendered. So there we have a pyramid

to show how the provider is not on an island alone; what services the

provider performs must be supported by documentation.

Many insurance carriers have adopted the same guidelines used by

Medicare and Medicaid as their own standards. Other entities have entered

into the picture to set standards for the medical charts. One of these

entities, the Joint Commission, is an organization that provides standards

There are a number of organizations that look at the facility to verify patient

safety and make sure the services that are reported are actually the ones

being performed at the facility. The medical record documentation is one of

the most important areas that these organizations will want to review when

looking at a healthcare facility. The documentation found in the medical

chart is a legal document. It represents to standards by which the facility

operates. The importance of the medical document cannot be overstated.

Data Mapping and Bell Curves

The purpose of a bell curve is to limit your organization's vulnerability to an

insurance audit. A good way of doing this is through comparing benchmarks

private carriers, to do a quick evaluation of a provider’s billing levels. There

are many things that can be discovered about a provider’s billing levels from

these bell curves.

that leads to improper payments. It is vital that organizations monitor

coding accuracy, as well as trends in regard to code use, through auditing

and compliance programs. Take a look at the Module Four Comparison

Chart Spreadsheet for a visual of a bell curve.

Compliance audits are performed to examine the proficiency of the provider

and the coding staff on regulations regarding coding and billing. Every claim

in the practice is not audited; instead, a random sample is selected. If the

random sample indicates a need for further review, then more charts will be

selected. If the initial claims do not indicate any issues, then no further

actions are necessary for the auditor. One of the initial indications of an

management (E&M) codes billed. There should be a spread of codes

indicating that all codes are being used. Being outside the range of codes