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Because providers rely on documentation to communicate important patient information, incomplete and inaccurate documentation can result in unintended and even dangerous patient outcomes. Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse.
Guidelines for Medical Record Documentation. Consistent, current and complete documentation in the medical record is an essential component of quality patient care. The following 21 elements reflect a set of commonly accepted standards for medical record documentation.
The CERT Statistical Contractor determines how claims are sampled and calculates any improper payments. The CERT Review Contractor requests and reviews medical records from providers and suppliers. Submit enough documentation to support your claims.
Ethical Standards. Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding and reporting of high-quality healthcare data used for both individual patients and aggregate reporting.
The selected claims and associated medical records are reviewed for compliance with Medicare coverage, coding, and billing rules. Remember: Providers should submit adequate documentation to ensure that claims are supported as billed.
Learn about proper medical record documentation requirments; how to provide accurate and supportive medical record documentation. Download the Guidance Document Final
By focusing on these three principles of documentation, a short, concise note may effectively take the place of pages of excessive verbiage and thus bring greater efficiency to the burden of record-keeping, while simultaneously achieving the goal of addressing critical risk management factors.