Medical insurance specialists work with important clinical data as well as demographic data. Health plans need patient clinical information to assess the medical necessity of claims sent for payment. To provide the right level of care, other physicians need to know the results of tests and examinations that patients have already had. Keeping all patient data safe and secure is the job of everyone on the healthcare team. But it is no longer a job of managing stacks of paper files. Like shopping, buying tickets, banking, and sharing photos online, healthcare records are moving to a digital platform. Working in this envi- ronment requires knowledge of electronic health records and of the federal rules that regulate access to them. Medical insurance
2.1 Medical Record Documentation: Electronic Health Records A patient’s medical record contains facts, findings, and observations about that patient’s health history. The record also contains communications with and about the patient. In a physician practice, the medical record begins with a patient’s first contact and continues through all treatments and services. The record provides continuity and communication among physicians and other healthcare professionals who are involved in the patient’s care. Patients’ medical records are also used in research and for education.
medical record file containing the documentation of a patient’s medical history and related information
Medical Records Medical records, or charts, contain documentation of patients’ conditions, treatments, and tests that are created and shared by physicians and other providers to help make accurate diagnoses and to trace the course of care.
COMPLIANCE GUIDELINE Medical Standards of Care and Malpractice
Medical standards of care are state-specified performance measures for the delivery of healthcare by medical professionals. Medical malpractice can result when a provider injures or harms a patient because of failure to follow the standards. Medical insurance
malpractice failure to use professional skill when giving medical services that results in injury or harm
A patient’s medical record contains the results of all tests a primary care physician (PCP) ordered during a comprehensive physical examination. To follow up on a prob- lem, the PCP could refer the patient to a cardiologist, also sending the pertinent data for that doctor’s review. By studying the medical record, the specialist treating a referred patient learns the outcome of previous tests and avoids repeating them unnecessarily.
Documentation means organizing a patient’s health record in chronological order using a systematic, logical, and consistent method. A patient’s health history, examina- tions, tests, and results of treatments are all documented. Complete and comprehensive documentation is important to show that physicians have followed the medical standards of care that apply in their state. Healthcare providers are liable (that is, legally respon- sible) for providing this level of care to their patients. The term medical professional liability describes this responsibility of licensed healthcare professionals. Medical insurance
Part 1 WORKING WITH MEDICAL INSURANCE AND BILLING
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documentation recording of a patient’s health status in a medical record
medical standards of care state-specified performance measures for the delivery of healthcare 35
Patient medical records are legal documents. Good medical records are a part of the physician’s defense against accusations that patients were not treated correctly. They clearly state who performed what service and describe why, where, when, and how it was done. Physicians document the rationale behind their treatment decisions. This rationale is the basis for medical necessity—the clinically logical link between a patient’s condition and a treatment or procedure. Medical insurance
COMPLIANCE GUIDELINE Documentation and Billing: A Vital Connection
The connection between docu mentation and billing is essential: If a service is not documented, it cannot be billed. Advantages of Electronic Health Records
Because of their advantages over traditional paper records, electronic health records are now used by the majority of physician practices. Electronic health records (EHRs) are computerized lifelong healthcare records for an individual that incorporate data from all sources that treat the individual.
EHRs are different from electronic medical records (EMRs), which are computerized records of one physician’s encounters with a patient over time that are the physician’s legal record of patient care. EHRs are also different from a third type of electronic record, personal health records (PHRs), which are private, secure electronic files that are created, maintained, and controlled by patients and contain data such as their current medications, health insurance information, allergies, medical test results, family medical history, and more.
BILLING TIP Medical Necessity Services are medically necessary when they are reasonable and essential for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Such services must also be consistent with generally accepted standards of care.
Documents in electronic health records may be created in a variety of ways, but they are ultimately viewed on a computer screen. For example, one general practice uses a number of medical-history-taking templates for gathering and recording “con- sistent history and physical information from patients.” The computer-based tem- plates range in focus from abdominal pain to depression, with from ten to twenty questions each. The on-screen templates are filled out in the exam rooms. Respon- sible providers then sign the entries, using e-signature technology that verifies the identity of the signer. Medical insurance
EHRs offer both patients and providers significant advantages over paper records:
▸ � Immediate access to health information: The EHR is simultaneously accessible from computers in the office and in other sites such as hospitals. Compared to sorting through papers in a paper folder, an EHR database can save time when vital patient information is needed. Once information is updated in a patient record, it is available to all who need access, whether across the hall or across town.
▸ � Computerized physician order entry management: Physicians can enter orders for pre- scriptions, tests, and other services at any time. This information is then tr ansmitted to the staff for implementation or directly to pharmacies linked to the practice.
▸ � Clinical decision support: An EHR system can provide access to the latest medical research on approved medical websites to help medical decision making.
▸ � Automated alerts and reminders: The system can provide medical alerts and reminders for office staff to ensure that patients are scheduled for regular screenings and other preventive practices. Alerts can also be created to identify patient safety issues, such as possible drug interactions.
▸ � Electronic communication and connectivity: An EHR system can provide a means of secure and easily accessible communication between physicians and staff and in some offices between physicians and patients. Medical insurance
▸ � Patient support: Some EHR programs allow patients to access their medical records and request appointments. These programs also offer patient education on health topics and instructions on preparing for common medical tests, such as an HDL cholesterol test.
▸ � Administration and reporting: The EHR may include administrative tools, including reporting systems that enable medical practices to comply with federal and state reporting requirements.
▸ � Error reduction: An EHR can decrease medical errors that result from illegible chart notes because notes are entered electronically on a computer or a handheld device.
Chapter 2 ELECTRONIC HEALTH RECORDS, HIPAA, AND HITECH
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Nevertheless, the accuracy of the information in the EHR is only as good as the accuracy of the person entering the data; it is still possible to click the wrong button or enter the wrong letter.
BILLING TIP Hybrid Record Systems Although the majority of physician practices use EHRs, most also still have paper records. The use of electronic along with paper records is called a hybrid record system.
Documenting Encounters with Providers Every patient encounter—the meeting, face-to-face or via telephone or emessaging, between a patient and a provider in a medical office, clinic, hospital, or other location— should be documented with the following information: Medical insurance
encounter visit between a patient and a medical professional
▸ � Patient’s name ▸ � Encounter date and reason ▸ � Appropriate history and physical examination ▸ � Review of all tests that were ordered ▸ � Diagnosis ▸ � Plan of care, or notes on procedures or treatments that were given ▸ � Instructions or recommendations that were given to the patient ▸ � Signature of the provider who saw the patient
In addition, a patient’s medical record must contain:
▸ � Biographical and personal information, including the patient’s full name, date of birth, full address, marital status, home and work telephone numbers, and employer information as applicable
▸ � Records of all communications with the patient, including letters, telephone calls, faxes, and e-mail messages; the patient’s responses; and a note of the time, date, topic, and physician’s response to each communication
▸ � Records of prescriptions and instructions given to the patient, including refills ▸ � Scanned records or original documents that the patient has signed, such as an authorization
to release information and an advance directive ▸ � Drug and environmental allergies and reactions, or their absence ▸ � Up-to-date immunization record and history if appropriate, such as for a child ▸ � Previous and current diagnoses, test results, health risks, and progress ▸ � Records of referral or consultation letters ▸ � Hospital admissions and release documents ▸ � Records of any missed or canceled appointments ▸ � Requests for information about the patient (from a health plan or an attorney, for Medical insurance
example), and a detailed log of to whom information was released
Medicare’s general documentation standards are shown in Table 2.1.
Evaluation and Management Services Reports When providers evaluate a patient’s condition and decide on a course of treatment to manage it, the service is called evaluation and management (E/M). Evaluation and management services may include a complete interview and physical examination for a new patient or a new problem presented by a person who is already a patient. There are many other types of E/M encounters, such as a visit to decide whether surgery is needed or to follow up on a patient’s problem. An E/M service is usually documented with chart notes.
evaluation and management (E/M) provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it Medical insurance
Also check: Health Care Strategic Management