Submitted by Safeguard Services LLC, A Medicare Program Safeguard Contractor

There is no doubt about it – in today’s world, concise documentation is critical.  Not only to provide quality patient care but also to obtain timely reimbursement from various insurers, such as Medicare. 

Medicare has specific guidelines when it comes to documentation, and the Program Safeguard Contractor must keep this fact in mind whenever we review documentation.  Unfortunately, on many occasions, we find that the documentation we receive is not as concise as it should be.  Sometimes, it is something as simple as legibility.  On other occasions, we find documentation issues that are more pronounced such as “cookie cutter” templates where all patients are getting the same procedure, with the same complaint, the same findings, and the provider is treating them all with the same exact plan of care.  

Services billed to the Medicare program are the sole responsibility of the Medicare provider.  Your documentation needs to be unique, specific, and should accurately reflect the services you are billing. 

 The services billed should be individualized to the presenting problem(s) on the date in question.  You want to record everything that is done.  It doesn’t matter how routine it is – write it down!  

It is also important to be specific when it comes to the services provided.  If you gave an injection, what was the medication and how much was injected?  How was the medication administered?  Where was it administered?  Who administered the medication?  Did the patient have a reaction to the medication?  Was any medication discarded?  Was it medically necessary?  The same thing holds true for an E&M service.  Who performed the service? What was performed (give detail)?  When was it performed?  Where was it performed?  Many times, you will find that Medicare documentation requirements are located right in the Local Coverage Determinations, which are accessible from the Centers for Medicare and Medicaid Services (CMS) Web site. 

A few other documentation tips to keep in mind include:

• If your notes are handwritten, make sure they are legible.  If the reviewer can’t decipher your documentation, they might not be able to allow the service.
• If you perform a test, be certain that the order is noted somewhere in the medical record.
• Include history documents to help substantiate services.
• When billing for timed codes, make certain your documentation clearly reflects the time you spent.    

The Centers for Medicare and Medicaid Services has an Evaluation & Management Services Guide that can be accessed in the product catalog of The Medicare Learning Network (MLN).  This resource will provide you with a brief but detailed overview of the principles that should be followed for medical record documentation.