Medical Record Documentation Guidelines
Complete and accurate documentation in the medical record is an essential part of quality patient care. In addition, it is fundamental to ensuring compliance with CMS and NCQA billing guidelines.
The following is being provided to ensure that all AgeWell New York providers are knowledgeable about what constitutes a compliant medical record and to provide the tools to support proper coding and documentation of diagnoses in the medical record.
KEY COMPONENTS OF A COMPLIANT MEDICAL RECORD
Legibility: All entries in the medical record must be legible. While a digital or typed record is ideal, any handwritten entries in a medical record must be easily read. Poor handwriting may be responsible for legibility issues, as are the use of acronyms that are not otherwise widely used by the medical community.
Patient identification on each page: Each page of the medical record should clearly identify the patient. Utilization of at least two patient identifiers is required. Acceptable patient identifiers include patient’s first and last name along with either date of birth, account number or medical record number. Alternatively, if the pages following the first page documenting a patient visit do not include patient identifiers, entries such as page number (coupled with visit date) may be used to ensure that a reviewer of the record can easily determine that the pages reference the same visit.
Visit date: The medical record must include the date of the patient’s visit, including month, day and year.
Telehealth: Telehealth visits may be documented as a face-to-face visit only when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.
Provider name, credentials, and signature: Each encounter in the medical record should include a legible signature of the provider’s name and credentials (e.g.: MD, DO, NP, PA, etc.) The provider name and credentials may be pre-printed in a documentation form, in which case the form should be separately signed by the provider. An electronic signature is also acceptable. In this case, the record must indicate that the record was signed electronically.
DOCUMENTATION OF BILLED DIAGNOSTIC CODES
AgeWell New York adheres to the ICD-10-CM Official Coding Guidelines, which are released an updated annually. If an ICD-10-CM code is billed by a provider, the following documentation must be present:
Diagnosis by appropriate provider: Only a physician or other qualified and licensed provider legally accountable for establishing a patient’s diagnosis can “diagnose” a patient.
All billed diagnoses must be documented: Written documentation to substantiate a billed diagnostic code must be included in the notes for the date of service associated with the claim. The existence of “history of” a diagnosis is not sufficient. If the information does not exist in the visit note, CMS considers that it did not happen. CMS looks for a full description of the patient’s condition. A diagnosis may only be coded when it is explicitly named in the medical record.
Each encounter: Documentation of an encounter must be complete and not depend on reference to another encounter. Therefore, statements such as “same as last visit” or “see results from <date>” are not acceptable.
Monitored, Evaluated, Assessed/Addressed, Treated (MEAT): ICD-10—CM Official Coding Guidelines specify that all conditions should be coded and documented which affect patient care, treatment and management. Evidence of any billed diagnosis codes should be described fully described in the medical record, except for status codes (see below). This documentation may be described as MEAT and should validate that the condition was Monitored, Evaluated, Assessed/Addressed and/or Treated.
Diagnoses and the MEAT that support those diagnoses may be described in the patient’s:
- Problem list (HPI)
- Review of Systems (ROS)
- Physical Exam (PE)
- Treatment Plan
- Any additional free-form text portion of the medical record.
The information described above does not need to be present in a particular portion of the medical record documentation and need not appear together in the same section or portion of the note.
- Documentation of Medications Relating to Diagnoses: Notation of specific medications or other treatment relative to the diagnosis is considered adequate to demonstrate that a condition has been addressed during the visit, as long as the note specifies that the medication or treatment is associated with the specific diagnosis. This is especially important when medications are listed in a separate Medication List without correlating information.
- Documentation of Referral for Specific Diagnosis(es): Documentation of referral to a specialist for a specific condition also meets criteria. An explanation of the specific treatment to be rendered by the specialists is not required.
Chronic conditions: A chronic condition must be restated in the medical record each time it is assessed or treated by the provider and billed on a claim. A chronic condition may be coded and reported as many times as the patient receives treatment and care for the condition(s). Note that chronic conditions may not be carried visit-over-visit or year-over-year without specific documentation of assessment and plan. At the beginning of each year, CMS sets a patient’s diagnosis burden to “zero”; therefore, each chronic condition should be assessed and documented at least once per year.
Historical conditions / Status Codes: Do not code conditions that have been successfully treated and no longer exist in the patient. However, do code any relevant “status codes” representing late status of an historical event (i.e., toe amputation status, previously amputated”). Such statuses can and should be coded even if no specific attention (“MEAT”) is paid to the issue during the current visit, due to the historical nature of these codes. Status codes that represent a current medical regimen (i.e., renal dialysis status; long-term insulin use) may also be coded without MEAT.
Conditions “in remission”: When a provider documents that a condition is “in remission”, the condition may be considered a Status Code and may be coded without further MEAT, as the term “remission” is considered as the relevant status reflecting the progress of the condition. When a provider codes a condition “in remission” and documents “history of…” or lists it in the Past Medical History section of the medical record, it may be coded if MEAT is present to indicate that the condition is having an impact on treatment.
For certain cancers, such as breast, prostate, lung, etc., documenting it as ‘in remission” may not mean that the disease is entirely eradicated. If treatment is being received it should be coded as an active cancer. If no treatment is being received, consider this to be a “history of” the specified cancer.
For other chronic diseases which are cyclical in nature, with intermittent symptoms, any such conditions documented as being “in remission” should still be coded as an active condition. Examples include Crohn’s disease, lupus, rheumatoid and other forms of arthritis, multiple sclerosis, etc.
Note that “history of” in ICD coding specifically means that the condition has resolved and is no longer present. However, “history of” can have two different meanings (e.g., chronic condition or the condition no longer exists). Documentation should clearly state whether or not a condition is chronic and still impacts the patient’s health management or that the condition no longer exists.