Medical record documentation is required to record pertinent facts about an
individual's health history. It is also serves as a legal document to
substantiate payment for our services as providers. For these reasons our
documentation must be dated, accurate, legible and consistent with
documentation principles established by CMS
(formerly HCFA). The CPT and ICD-9-CM
codes reported on the health insurance claim or billing statement should be
supported by the documentation in the medical record to ensure appropriate
In 1994, CMS (HCFA) and the AMA
released the "Documentation Guidelines for Evaluation and
Management Services". These were revised in 1997 and in 2006. The 2006
changes came about, in part, from the efforts of AMDA [the American Medical
Directors Association], AGS [the
American Geriatrics Society], AAFP [the American Academy of Family
Physicians], and AAHCP [the American Academy of
Home Care Physicians].
In order to learn these guidelines, and to follow their documentation
requirements, we developed a summary chart to prompt our providers in their
documentation. This chart covered the billing codes encountered in Nursing
Facilities and Assisted Living Facilities [Domiciliary]. It also includes the
Medicare rates for these codes and compares them to the 2005 rates. The chart
is available for purchasing in our Consulting Services Section.
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