Medicare pays physicians based on diagnostic and procedure codes derived from medical documentation. That’s why proper medical record documentation is crucial to providing patients with quality care as well as receiving accurate and timely reimbursement for furnished services.
Training practitioners to better document their visits can frustrate auditors like nothing else. And it makes sense, it’s not easy to approach a doctor and effectively tell them how to better do their jobs. It’s the physician's responsibility to ensure documentation reflects the services furnished and the codes selected to reflect those services accurately.
Use this free E/M Documentation Checklist, to assist providers when responding to medical record documentation requests pertaining to evaluation and management services.
Get the printout and pat yourself on the back for being so clever and on top of your audit game. The checklist includes the principles of medical documentation for submission, supporting documentation for the level of service, and supporting documentation for medical necessity.