This is especially important when medications are listed in a separate Medication List without correlating information. Documentation of Medications Relating to Diagnoses: Notation of specific medications or other treatment relative to the diagnosis is considered adequate to demonstrate that a condition has been addressed during the visit, as long as the note specifies that the medication or treatment is associated with the specific diagnosis.The information described above does not need to be present in a particular portion of the medical record documentation and need not appear together in the same section or portion of the note. Any additional free-form text portion of the medical record.This documentation may be described as MEAT and should validate that the condition was Monitored, Evaluated, Assessed/Addressed and/or Treated.ĭiagnoses and the MEAT that support those diagnoses may be described in the patient’s: Evidence of any billed diagnosis codes should be described fully described in the medical record, except for status codes (see below). Monitored, Evaluated, Assessed/Addressed, Treated (MEAT): ICD-10-CM Official Coding Guidelines specify that all conditions should be coded and documented which affect patient care, treatment and management. Therefore, statements such as “same as last visit” or “see results from ” are not acceptable. A diagnosis may only be coded when it is explicitly named in the medical record.Įach encounter: Documentation of an encounter must be complete and not depend on reference to another encounter. CMS looks for a full description of the patient’s condition. If the information does not exist in the visit note, CMS considers that it did not happen. The existence of “history of” a diagnosis is not sufficient. If an ICD-10-CM code is billed by a provider, the following documentation must be present:ĭiagnosis by appropriate provider: Only a physician or other qualified and licensed provider legally accountable for establishing a patient’s diagnosis can “diagnose” a patient.Īll billed diagnoses must be documented: Written documentation to substantiate a billed diagnostic code must be included in the notes for the date of service associated with the claim. DOCUMENTATION OF BILLED DIAGNOSTIC CODESĪgeWell New York adheres to the ICD-10-CM Official Coding Guidelines, which are released an updated annually. In this case, the record must indicate that the record was signed electronically. An electronic signature is also acceptable. Provider name, credentials, and signature: Each encounter in the medical record should include a legible signature of the provider’s name and credentials (e.g.: MD, DO, NP, PA, etc.) The provider name and credentials may be pre-printed in a documentation form, in which case the form should be separately signed by the provider. Telehealth: Telehealth visits may be documented as a face-to-face visit only when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication. Visit date: The medical record must include the date of the patient’s visit, including month, day and year. Alternatively, if the pages following the first page documenting a patient visit do not include patient identifiers, entries such as page number (coupled with visit date) may be used to ensure that a reviewer of the record can easily determine that the pages reference the same visit. Acceptable patient identifiers include patient’s first and last name along with either date of birth, account number or medical record number. Utilization of at least two patient identifiers is required. Patient identification on each page: Each page of the medical record should clearly identify the patient. Poor handwriting may be responsible for legibility issues, as are the use of acronyms that are not otherwise widely used by the medical community. While a digital or typed record is ideal, any handwritten entries in a medical record must be easily read. Legibility: All entries in the medical record must be legible. KEY COMPONENTS OF A COMPLIANT MEDICAL RECORD The following is being provided to ensure that all AgeWell New York providers are knowledgeable about what constitutes a compliant medical record and to provide the tools to support proper coding and documentation of diagnoses in the medical record. In addition, it is fundamental to ensuring compliance with CMS and NCQA billing guidelines. Complete and accurate documentation in the medical record is an essential part of quality patient care.
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