Keys To Keeping Good Medical Records

Medical records are an important part of any medical practice.  Keeping good records is essential in avoiding an audit or possibly not getting payment from an insurance company.  Several auditing groups include, licensing boards, payers, litigants, accreditation organizations, each one is looking for specific things in the documentation.  Licensing boards want to find out if the doctor acted within his or her scope of practice or if they were grossly negligent.  Payers want to determine if a claim is justified for reimbursement.  Litigants want to know whether a breach happened during care.  Accreditation organizations want to determine if their standards and elements of performance have been met by the doctor.

These are some general requirements for documentation.

  1. Medical Records should be complete and are legible.
  2. Documentation of each patient that is being seen should include a reason for the visit and a history that is relevant to the complaint, physical examination findings and any prior diagnostic test results, a full assessment and clinical impression and diagnosis, a plan for care and date the record along with signature of attending physician, nurse etc.
  3. Reason for ordering tests.  If this is not recorded, it can be easily proved that it was not necessary.
  4. Past and present diagnoses whether it be from the patient or other past office visits from other physicians.
  5. Appropriate health risk factors should be identified and noted.
  6. Patient’s progress, response to changes in treatment, and a change of diagnosis should be clearly documented.
  7. The CPT and ICD-9 codes reported on the insurance claim form should always be supported by the documentation in the medical record.

Meeting the standard of care medical records must:

  1. Document any details regarding a patient’s history during the exam
  2. Document referrals
  3. Document refusals of treatment and the reason the patient has refused treatment
  4. Document that the physician has clearly reviewed the possible consequences of refusing a specified treatment to the patient
  5. Document encouragement of the physician of healthcare maintenance and risk reduction (example: weight loss or smoking)
  6. Document advice that has been given to the patient (example: pink eye can spread to others in the family)
  7. Document patient noncompliance with treatment regimen or referral, including the patient’s reason for not complying and advice to the patient about the risk of failing to take the advice given.

Good medical record keeping is an important part of good business.  The consequences of errors can result in a denial of payment, audit, loss of contracts, accreditation or possible lawsuit brought on by a patient.  It may take longer to do but in the end it benefits you, your practice and most important of all your patients.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at http://www.inscoding.com/aboutus.php

Click here to read testimonies regarding MariAnn Medical Billing Service http://www.inscoding.com/testimonials.php

“Like” us on Facebook at http://www.facebook.com/pages/MariAnn-Medical-Billing-Service/224754564210246 

 

 

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How Do You Know If Your Practice Is On Target?

Many physicians are overwhelmed with their day-to-day activities and are not aware if their practice is doing well or is in need of some fine tuning.  Below are five key areas of concern that should be looked into and followed up on to see how the practice is flowing.

1. Overhead

Calculate your overhead rate which includes staff and general operating costs by the total revenue the practice is bringing in.  Do some research on other practices similar to yours and see if they are comparable.  If your overhead rate is higher than the average for your specialty, consider reviewing all the cost that are involved within your practice and see if there are areas where you can reduce expenses.

2.  How productive is your practice

It’s a good idea from time to time to check the amount of referrals you are getting every month.  Make a spreadsheet of all referring doctors and see where possibly there is a drop in referrals or you are seeing an increase in referrals for a specific doctor.  By a physician taking 10 minutes out of their day to call a physician to remind them of your practice and also thank them for referring patients in the past, this could generate future referrals for the practice.

3.  Access the practices financial situation

Start by calculating a net collection rate.  When you enter into a contract with an insurance company, you agree to take a contractual adjustment from your submitted charges.  The net collection rate tells you whether you are collecting the remainder of your submitted charges once the adjustment has been made.  Calculate your net collection rate.  It should be 97% or greater to ensure a healthy bottom line.

4.  Avoid unnecessary hospital admissions or ER Visits

Evaluate a one month period and calculate the number of ER visits and admissions that were avoidable or potentially avoidable.  If your practice has a high level of preventable visits and admissions, create a quality plan to expand continuity of care, transition management, and care outreach.  Track this over time by checking it on a quarterly basis, with the goal of reducing your practice’s rate to zero.

5.  Survey referring physicians and patients

Many offices now use a patient survey or referring physician survey to evaluate their practice better.  This could be something that could be e-mailed or mailed with a return postage envelope to patients and referring doctors.  It can be done unanimously to protect their privacy as well.  This is an excellent tool to use to find out what’s really going on with the practice.  This data can be analyzed and put into good use to further make changes within the practice to help it run better.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at http://www.inscoding.com/aboutus.php

Click here to read testimonies regarding MariAnn Medical Billing Service http://www.inscoding.com/testimonials.php

“Like” us on Facebook at http://www.facebook.com/pages/MariAnn-Medical-Billing-Service/224754564210246