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These guidelines were a combined effort between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) to standardize the documentation of patient services.
The guidelines are as follows:
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| 1. |
The medical record should be complete and legible. |
| 2. |
The documentation of each patient encounter should include the date; the reason for the encounter; appropriate history and physical examination; review of laboratory results, x-ray data, and other ancillary services, where appropriate; assessment and plan for care (including discharge service, if appropriate). |
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Past and present diagnoses should be accessible to the treating and/or consulting physician. |
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The reasons for and results of x-rays, laboratory tests, and other ancillary services should be documented or included in the medical record. |
| 5. |
Relevant health risk factors should be identified. |
| 6. |
The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient noncompliance, should be documented. |
| 7. |
The written plan for care should include, when appropriate, treatments and medications, specifying frequency and dosage; any referrals and consultation; patient/family education; and specific instructions for follow-up. |
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Documentation should support the intensity of the patient’s evaluation and treatment, including thought processes and the complexity of medical decision making. |
| 9. |
All entries must be dated and contain the identification of the provider of the service. |
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Reported Physicians’ Current Procedural Terminology (CPT) and International
Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) codes must be supported by the documentation in the medical record. |
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| We research new codes for use on January 1st each year. And our Staff will do the following: |
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Identify the service or procedure to be coded. |
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Look up the appropriate term in the index. |
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Assign a tentative code. |
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Locate the code or codes in the appropriate section. |
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Determine whether any modifiers should be used. |
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Assign the code. |
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Staff may know how to fill out the forms and where to send them, but do they really understand and use the information in the explanation of benefits that they receive from Medicare and other third party payers.
Trying to comply with all of the new Medicare rules and regulations is not only confusing, but vexing. Staff must be well acquainted with the Physicians’ Current Procedural Technology (CPT), International Classification of Diseases, Ninth Revision,
Clinical Modifications (ICD-9-CM), and HCPCS level II(two) codebooks. |
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The ICD-9-CM disease codes are extremely precise and require some medical knowledge to understand them. Medical office staff should have some clinical background or understanding of medical terminology to be able to select the correct code for a particular claim.
It is the physician’s responsibility to provide the office staff with a diagnosis for each patient. |
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| The following is a sampling of these guidelines: |
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Identify each service or procedure with a diagnosis code. |
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Identify services for circumstances other than disease or injury with a V code. |
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Code to the highest degree of specificity by using fourth and fifth digits. |
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Code chronic diagnoses when applicable to that specific patient visit. |
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For ancillary services, code the appropriate V code first, and then code the problem second. |
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For surgical procedures, code the diagnosis applicable to the procedure. If the postoperative diagnosis is different from the preoperative diagnosis, code using the postoperative diagnosis. |
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Do not code using “probable,” “suspected,” “Rule out,” or “questionable.” |
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