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Encouraging physician documentation

HIM Connection, January 6, 2004

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Encouraging physicians to improve their documentation could improve reimbursement for your facility. Third-party payers view physician documentation as the most important determinant of how much they will reimburse both the physician the facility. First of all, third-party payers generally only have to reimburse for "medically necessary services." The content of the medical record provides the only source of information that can be used to determine whether a service is medically necessary.

Therefore, physicians must document their findings and assessments in enough detail to validate the medical necessity of each admission, procedure, or transfer to a different level of care. Failure to do so may lead to a denial of payment to both the physician the facility.

The level of reimbursement depends on the specific codes for care that the physician and facility submit to the third-party payer. Coders rely completely on documentation in the medical record as the basis for selecting codes for submission for payment. Physicians must learn the key elements of physician documentation that impact reimbursement for common conditions treated by the physician's specialty.

Delays in physician documentation (such as in dictating the H&P, operative report, and discharge summary) can lead to delays in submission of claims and payment to the physician or facility.

Give physicians the following tips to improve their documentation practices:

1. Document when the care is provided.

2. Understand that H&Ps, operative reports, diagnostic tests, and treatment orders are critical for accurate coding.

3. Document the patient's severity of illness and your clinical rationale for ordering the intensity and level of care you are prescribing.

4. Be open to suggestions on appropriate language for documentation made by the case managers and coders in your facility.

5. Never compromise your integrity in order to improve reimbursement; always document accurately.

This week's excerpt is from "Documentation Improvement Handbook for the Medical Staff," by Jean S. Clark, RHIA and Richard A. Sheff. Click here for more information or to order.

Check out the Editor's Choice section below for solutions to your records completion problems.

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com

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