Documentation is the most important element, if it is not documented, it did not happen.
Documentation provides evidence of the clinical service provided to the patient. It is used to communicate to other clinicians, billing and coding, insurance companies and other healthcare entities.
Why it matters:
- Provide the best patient care
- Ensure consulting physicians have accurate information
- Justify level of service and necessity of ancillary services
- Obtain appropriate reimbursement
- Protect your practice from audits
New Patient vs. Established patient
- New patient visits require 3 of the 3 components to be documented
- Established patient visits require 2 of the 3 components documented
Common mistakes in physical exam documentation:
- A new patient needs a least 6 bullet points to code a 99202
- We often down code to a 99201 because 5 or less exam bullets are documented
- Copied or duplicated notes from prior visits
- Not reporting negative findings
- If you examine a body area, mention it even if it is normal.
- Documentation of benign finding is important as it allows the biller to assign additional diagnosis codes.