Documentation in Medical Record

Kisselml

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Wanted to get clarification on requirements in the Medical Record. My team has been instructed to bill claims missing results or interpretations from the Medical Record as long as it is located somewhere else in the Health Record. However, we don't have access to verify these other locations and are to assume it's there, where ever there is.

Examples being lab tests, x-rays, EKG etc...

We are also not to review E/M levels and bill as is.

So basically we're just making sure charges are on claims.

Thanks
 

Pathos

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Sounds like your role is a Biller in your practice. However, as a rule of thumb, the Medical Record must support medical necessity no matter the procedure or diagnosis codes. As CMS is often quoted saying:"If it wasn't documented, it didn't happen". Depending on the procedure and diagnosis codes, there are specific requirements of what would support any given code, and (sometimes) what is inappropriate. Without any more specific examples, it would be difficult to pin point further Medical Record requirements.

Hope this helps!
 

Kisselml

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For instance, all labs done are scanned into the patient record under scanned images same for x-ray reports.

Does the information, results or interpretation, need to be on the specific encounter's chart notes or can it just be somewhere in the Health Record.

This is where I am getting conflicting information. Provider feels that it can be justified later if need be and not to worry about making sure everything is documented in the encounter notes.
 
Last edited:

thomas7331

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There is no requirement that information be located in a particular part of the record, and it is not necessary to duplicate information from one part of the medical record to another. As long as documentation to support the information billed on your claim for that date of service is in the record and is available to an auditor or peer in the event that the chart is reviewed, then there should not be a problem with the results being in a different part of the chart from the encounter note itself.
 
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