By Stuart A. Bussey, M.D., J.D., UAPD President
There is a delicate balance between documentation and insurance reimbursement. Insufficient records can mean rejected claims, while excessive and unsupported coding can invite an audit, EMR templates may tempt a provider to clone his/her reports and that would be a mistake. One size does not fit all. Notes should be as precise as possible. Most doctor’s notes are not complete enough to meet coding and billing requirements. An even greater cause of records audits is “medically unnecessary” treatment. In order to show that treatment is medically necessary the patient record should tell a story. The chief complaint is like the title of the story, while the history sets it up and the exam fills in the details. Your medical decision making is the end of the story. Besides the usual SOAP components of the record are contributory notes which can upgrade your reimbursements. Individual counseling, coordination of care and exact time spent with the patient can augment payment. Besides legibility your records should present a clear rationale for ordering diagnostic and ancillary services, cover past and present diagnoses, health risk factors and report on the patient’s response to treatment. CPT and ICD-9 codes must be supported by the record. A weekend coding workshop for you and/or your staff may pay big dividends for you.