Documentation is a critical undertaking in any specialty Medical facility. It is an essential tool for conveying essential clinical information about each patient’s diagnosis, treatment, and results and for communication between physicians, medical billers and coders and the payers. Doctors and their team of medical billers must efficiently respond to the questions that payers are asking about each service.

The questions such as:

• Is it medically necessary?
• Is it a procedure that requires the knowledge and skills of a speech-language pathologist?
• Are the treatment goals functionally relevant?
• How do the procedures applied add value to the patient’s interdisciplinary care and overall health?

Because of the diversity challenges of settings and payer regulations, revenue cycle management specialists do not dictate a single format or timeframe for documentation. State or federal agencies governing health care or permits for speech-language therapy may have specific requirements. If those requirements are more stringent, they surpass requirements of facilities, payers, and employment contractors.

As the famous saying in Medicare documentation goes, “If you didn’t document it, you didn’t do it.”

Remember that unclear, error laced or absent documentation can result in denials by payers and make it difficult for the reader to follow the clinical judgment underlying the diagnosis and treatment. Other areas of knowledge necessary for documentation include coding and billing, requirements of the federal Health Insurance Portability and Accountability Act (HIPAA), and other key issues addressed below.

Documentation in Health Care Facilities

Documentation plays a vital role in communicating to third-party insurance payers the evaluation and treatment procedures/medical necessity and this is where you require the skill of an expert medical coder. Documentation necessities vary according to practice setting and by payer. For outpatient therapy documentation the guidelines serve as the standard for many other insurance plans.

Medical documentation is read by physicians as well as claims manager from varying backgrounds and experience. It is important that notes and reports are clear and legible and that they efficiently communicate all of the important information that is required for clinic management and reimbursement.

Documenting basically is a component to the delivery of healthcare. It is a tool to:

• Confirm continuity of care as it serves as a communication tool among healthcare providers
• Plan and evaluate a patient’s treatment
• Create a permanent record for the patient’s future care
• Create a database to evaluate effectiveness of treatment
• Facilitate research
• Substantiate medical billing and reimbursement
• Recollect a memory and/or justify/defend care provided.

Document intelligently and clearly to avoid allegation of falsifying a medical record:

• Date, time, and sign every entry
• Make charge entries immediately or soon after care is given
• Write legibly
• Be accurate, thorough, and objective
• Be careful with the abbreviations

Contemplating Documentation Challenges

Medicare documentation templates can play an important role in improving the efficiency of information collection, while making sure all relevant elements are collected in a structured format. But, these templates also have limitations:

• The templates may not exist for a specific problem or visit type. This issue can happen if the structure of the note is not a good clinical language and does not precisely reflect the patient’s condition and services
• Atypical patients may have not one but multiple problems or extensive interventions that must be documented, billed and coded in detailAlong with that the templates designed for reimbursement requirement may miss relevant clinical information. Also keep in mind that templates may also encourage over-documentation to meet reimbursement requirements even when services are not medically necessary or are never delivered.

Here are some important documentation tips:

1. Patient Identification for identification or demographic data documented and current

   The identification sheet includes all the data pertaining to the enrollee

2. Health History

   The Medical Billing coding staff needs to enter comprehensive health assessment completed or offered. If patient refuses to complete the form documentation should be present. Checklists are acceptable as well

3. Progress Notes

   This should include the reason for visit and why the patient came to see the practitioner

4. What are the physical findings

   What physical findings are found according to patient presenting complaints?

5. Lab and X-Ray reports

   What lab reporters are reviewed by the physicians? Are they signed or initiated by the doctor

6. Clearing medical billing errors

   The last and the most important document to the evaluated is the medical billing documentation to submit for claims reimbursement. One small mistake can lead to denial of your hard earned money

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