to: Office staff from: shatarra belton subject: documentation requirements needed for reimbursement date: July 17, 2016
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Billing Memo
This is a notice to all staff of the required documentation needed in order to receive proper reimbursement from insurance payers. As described previously, if the patient’s information is not documented in their medical record we cannot receive reimbursement for those services. We cannot bill for services that has not been documented, this is unethical and considered fraud. In order to avoid these issues we as staff must provide these minimum documentation in a patient’s chart. These documents are as follows: Chief Complaint of the patient for the date of service; the patient’s medical history; any physical exams performed on the patient at the time of service; new discoveries or findings will need to be documented; additional diagnostic testing ordered by the physician to include medical necessity of such testing; an assessment of the patient needs to be documented as well; a conclusion or doctor diagnosis must be documented if one is present at the time of visit; a treatment plan must be documented along with any doctor recommendation s for a follow-up visit.
In addition to minimum documentation requirements, there are some electronic solutions to help the staff ensure accurate evaluation and management coding. Those electronic solutions are included in our database, EZ Claims, as a claim scrubber. This claim scrubber will notify staff if we are billing inaccurate E&M codes based off documentation requirements in our EHR system. For example, if an established patient who is 18 years of age being seen on July 15, 2016 as one involving a detailed history, detailed examination and medical decision making of moderate complexity we know that this E&M code to use is 99214. If the incorrect code is being used, our EHR system will notify us immediately to correct the error. In the case this error slips through to our clearinghouse, Capario will then notify us of this error to correct before transmission to the insurance payer.