Documenting to Obtain Maximum Reimbursement
Your medical record is the evidence of what kind of care is given. Here is a checklist of charting components to understand when to obtain equitable reimbursement:-
Note: Be sure to record completely!
Documentation Components on Patient Record
- History: nature of presenting problem
- Physical examination
- Medical decision making: diagnoses, supporting data, risk, complexity
-
Note: Be sure to bill appropriately for time spent. Undercoding
is more common than overcoding.
Billable Components
- Time reviewing records
- Time face-to-face with client
- Care conferences without patient present
-
Note: Be sure to code the type of visit accurately.
Levels of Service for Office/Outpatient Services (based on history, acuity)
- Problem-focused
- Expanded
- Detailed
- Comprehensive
-
Note: These are called "E &
M" Codes (evaluation and management)
Visit the home page of the American Association of Family Practice for more background information on coding and documentation.
Work through the 4 cases for practice in recording thoroughly to maximize your reimbursement opportunities.
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Hint: Consider using checklists for charting
components (family & social history, review of systems, exam components)
Clinical Decision-Making Levels
- Straightforward
- Low complexity
- Moderate complexity
- High complexity
