Make Sure Your Documentation Meets Guidelines
Make Sure Your Documentation Meets Guidelines

July 17, 2019

I’m sure you’ve heard the saying, “if it isn’t documented, then it wasn’t done.” As a young graduate nurse, I learned this the hard way.
I’ll never forget when a surgery intern complained to my Head Nurse (as they were called in those days), at 7:20 am after my shift started at 7:00 am, that vital signs were not taken on his patient. “Oh yes,” I quickly answered when asked, “of course I took them” and proceeded to cite the patient’s normal vitals to the arrogant intern. To save face, the surgeon quickly pointed out that if the information was not in the chart, then the service hadn’t been provided. Never mind giving me a chance to get to the paper chart back in the early 1980s!
The moral of my tale is that I learned a great lesson that day, and it has stayed with me forever: if it isn’t documented, then it isn’t done. At least in the eyes of Medicare, other payors, and lawyers.

What I Say to Surgeons and Staff

In my twenty-plus years of physician practice management consulting, particularly with a focus on surgical coding and reimbursement issues, I’ve found that documentation is the only “leg” you’ll have to stand on when questioned by a payor, another provider, attorney, insurance company, or maybe even a patient. (Forget about those young haughty interns!)
Fortunately, most physicians and other providers are conscientious and want to ensure that their documentation is complete and compliant. It is important not only for providing patients with quality care, but also to ensure accurate and appropriate payment for the services you’ve provided.
I don’t have to tell you that the patient’s medical record is essential, in many ways, for reporting the care the patient received. Your documentation of pertinent facts, findings, diagnosis, and plan helps not only with your own care, but the care provided by other physicians and health care professionals, too. This is why your documentation needs to be personalized about the patient, and complete as well as compliant from a coding and billing perspective.

What CPT Says

Current Procedural Terminology® (CPT) guidelines, developed by the American Medical Association say that “Any service or procedure should be adequately documented in the medical record.” Do you think that could be any vaguer? This is why Medicare provides far more specific guidelines that we should follow.

What Medicare Says

Medicare has seven very specific things to say about provider documentation. These are called “the principles of documentation.” Compliance in your practice starts by adhering to these principles.
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For evaluation and management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service, and the patient’s status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

Medicare’s Principles of Documentation

Below are the seven principles of documentation that will guide your compliance journey. My comments are italicized.
1. The medical record should be complete and legible. [This makes sense, right?]
2. The documentation of each patient encounter should include:
o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results [In E/M terms, this is the Chief Complaint, History of Present Illness, Exam, Data Reviewed]
o Assessment, clinical impression or diagnosis [In E/M terms, this is your Diagnosis(es)]
o Plan for care
o Date and legible identity of the observer [An electronic signature works. If handwritten, then the provider’s name should be typed or handwritten clearly under the signature.]
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified. [This is important if you’re recommending a procedure and the patient’s comorbidities increase the patient’s surgical risk.]
6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
7. The CPT and diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. [This is why we do not recommend CPT and diagnosis codes in the operative report. If the codes in the operative report do not match the billed codes, it creates a compliance issue. I don’t know about you, but I oftentimes find incorrect codes in the operative note.]
For procedures performed at the same encounter as the E/M service, the above guidelines should be followed.
For surgical procedures performed in the operative room or other location, consider these same seven principles as your documentation guide. An “Indications for Surgery” paragraph helps.
Finally, make sure your documentation is legible.
I jokingly (well, maybe not) have always said that while I majored in Nursing at the University of Wisconsin, I also acquired a Minor in hieroglyphics because I can read physician handwriting.
My niece, also an RN, thinks this is funny because she’s never had to read actual physician handwriting – she trained in the era of the Electronic Health Record (EHR). Thank goodness for EHRs…or not…but that’s the subject of another blog.


CMS – MLN – Evaluation and Management Services Guide
CMS – MLN – Complying with Medical Record Documentation Requirements Fact Sheet
CMS – Your Medical Documentation Matters Handout
Palmetto GBA – JJ Part B – Evaluation and Management Services: Principles of Medical Record Documentation



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