Anyone who enters anything into a patient encounter must make sure the documentation is detailed, accurate and thorough. Now more than ever before “if you didn’t document it, it’s the same as if you didn’t do it.” Below are three examples that demonstrate why documentation is more important than ever before.
According to the U.S. Department of Health & Human Services Office of Inspector General (OIG) physicians should maintain accurate and complete medical records and documentation of the services they provide. In addition to ensuring patients receive appropriate care, good documentation practices helps address challenges raised against the integrity of bills – especially Medicare and Medicaid billing.
ICD-10-CM uses three to seven alpha numeric digits and full code titles. The changes in ICD-10-CM are in its organization and structure, code composition, and level of detail. For ICD-10-CM, good documentation practices are critical. Your documentation must be very specific about the details of procedures that are performed. With ICD-9, there were some “catch-all” codes; ICD-10 does not have these “catch-all” codes. To ensure proper reimbursement, your documentation must be specific and document in detail services that were provided to support ICD-10-CM codes.
Your documentation may be in either paper or electronic format – however, it is important to have it stored in one convenient location so that it is retrievable and reviewable upon request. If you are requested for an audit, the documentation will be used to validate that you accurately attested and to verify that the incentive payment was accurate. Therefore, it is extremely important that your documentation supports attestation data for meaningful use objectives and clinical quality measures.
As we mentioned in the opening paragraph “if you didn’t document it, it’s the same as if you didn’t do it.” For providers and healthcare organizations good documentation practices are more important than ever before – especially for ICD-10 and Meaningful Use purposes.