DOCUMENTATION GUIDELINES

 

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 payment.

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.

Revised 3/06

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