The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Tell the Whole Story
The 1995 Documentation Guidelines for Evaluation and Management (E&M) Services state that “Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes.” As such, the patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. The documentation in a patient’s record should demonstrate medical necessity for the service which Medicare indicates is the “overarching criterion for payment in addition to the individual requirements of a CPT code.” What does all this official, formal language mean to a physician? Simply, tell the patient’s story when documenting a visit. The record communicates information about the patient’s current status and shows what direction the physician is taking in the care and treatment of the patient. The chart record should be a complete and accurate account of the encounter. From the patient’s initial comments about their illness or injury to the ending with the details of a diagnosis and a plan. If it is a complete story, documentation will satisfy all the official language and rules.