Ophthalmology and Optometry Coding Alert

Question: Our practice is always looking for ways to bill better, but staying up with regulations and changes in the healthcare landscape makes clean documentation and billing a moving target. Do you have any recommendations for how we can improve the quality and accuracy of our documentation?

Iowa Subscriber

Answer: “Follow This Advice to Fortify Your Medical Records” in this issue exhorts you to keep your medical records consistent, current, and complete. To facilitate the first element, consistency, we suggest that you establish a checklist of basic requirements for medical record documentation based on the six core components identified by the National Committee for Quality Assurance (NCQA).

But before you finalize your checklist, peruse the other 15 commonly accepted standards for documentation, according to NCQA. To promote best-practice medical record keeping, consider incorporating the following into your practice’s checklist:

• Each page in the record contains the patient’s name or ID number.
• Personal biographical data includes the address, employer, home and work telephone numbers, and marital status.
• All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.
• All entries are dated.
• The record is legible to someone other than the writer.
• For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol, and substances (for patients seen three or more times, query substance abuse history).
• The history and physical examination identify appropriate subjective and objective information pertinent to the patient’s presenting complaints.
• Laboratory and other studies are ordered, as appropriate.
• Encounter forms or notes have a notation regarding follow-up care, calls, or visits, when indicated. The specific time of return is noted in weeks, months, or as needed.
• Unresolved problems from previous office visits are addressed in subsequent visits.
• There is review for under- or overutilization of consultants.
• If a consultation is requested, there is a note from the consultant in the record.
• Consultation, laboratory, and imaging reports filed in the chart are initialed by the practitioner who ordered them, to signify review. (Review and signature by professionals other than the ordering practitioner do not meet this requirement.) If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of follow-up plans.
• An immunization record (for children) is up to date, or an appropriate history has been made in the medical record (for adults).
• There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines.