Radiology Coding Alert

Keep focus on 5 W’s to avoid pitfalls.

Creating airtight medical records that can withstand all types of audit scrutiny is not an impossible goal. Taking the time to collect five simple pieces of information can move your record-keeping from "okay" to "exceptional."

TrailBlazer Medicare’s Sherrie Varner answered the question about how to create exceptional documentation in a webinar, "Medicare Documentation and Audits." Read on for her tips about the "Five W’s" that make medical records shine.

According to Varner, you should know the following:

• Who: Make sure you always list the performing, supervising, and referring practitioners.
• What (and how many): Always document the services and quantities of services performed.
• Where: Make note of the place of service.
• When: Never fail to record the date of service.
• Why: Ensure the diagnosis is documented and also report the ICD codes for the same. "This is the one where we frequently find more problems, making sure that practitioners are documenting medical necessity and the diagnosis," Varner said.

"We want you to paint us a picture," Varner said. "You know what’s happening with your patient, but that information has to be communicated from your head into the documentation that we receive."

You should also ensure that appropriate health risk factors are identified, and document the patient’s progress and response to treatment.

Timing isn’t written in stone: An attendee to the forum asked how long the physician has to complete a note after the patient is seen in the office. "That is kind of a gray area," Varner said. "There is nothing black or white, but we would generally expect 36 hours, something like that, is the normal time period. Preferably most people would do that on the same day, or if it’s dictated, maybe it would come back the next day."