Medi-Cal & Telehealth (California Medicaid)

Medi-Cal & Telehealth

The Department of Health Care Services (DHCS) considers telehealth a cost-effective alternative to health care provided in-person, particularly to underserved areas. Telehealth is not a distinct service, but a way that providers deliver health care to their patients that approximates in-person care. The standard of care is the same whether the patient is seen in-person or through telehealth.

DHCS’s coverage and reimbursement policies for telehealth align with the California Telehealth Advancement Act of 2011 and federal regulations. State law defines telehealth as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site.” This definition applies to all health care providers in California, not just Medi-Cal providers.

Medi-Cal also complies with federal regulations for telehealth, which are the same for Medicaid as they are for Medicare. Medicaid regulations authorize telehealth using “interactive communications” and asynchronous store and forward technologies. Interactive telecommunications must include, at a minimum, audio and video equipment permitting real-time two-way communication, according to the Centers for Medicare and Medicaid Services.

Medi-Cal pays for current Medi-Cal benefits appropriately provided via telehealth:
 • Selected Evaluation and Management (E&M) services for patient visit and consultation.
 • Selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services.
 • Teledermatology by store and forward.
 • Teleophthalmology by store and forward.
 • Transmission costs (up to 90 minutes per patient, per day, per provider).
 • Originating site facility fee.
 • Interpretation and report of X-rays and electrocardiograms performed via telehealth.

Please see the Medi-Cal Provider Manual: Telehealth for more information.

For additional information about Medi-Cal’s coverage and reimbursement telehealth policies, as well as resources for providers, please see the Telehealth Resources page.

For questions about submitting a claim for services provided by telehealth, please call the Telephone Service Center (TSC) at 1-800-541-5555.

Providers may email questions about Medi-Cal telehealth policy to Medi-Cal_Telehealth@dhcs.ca.gov.

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice http://www.physicianspractice.com/physician-compensation/new-measures-pay-performance-programs?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=31102013

Improve Medical Practice Efficiency by Offering Group Visits

As reimbursement declines and overhead increases, many practices are struggling to keep up. But rather than attempting to squeeze more patient visits into each day, has your practice considered seeing more patients per visit?

Perhaps it should. The number of practices offering group visits has increased from about two percent to three percent just two years ago to about 10 percent this year, practice management consultant Owen Dahl recently told Physicians Practice.

Here's more on how a group visit works, what it entails, and why your practice may want to consider it.

How a group visit works. During a group visit, multiple patients with similar chronic conditions (such as diabetes, osteoporosis, congestive heart failure, or COPD) meet at the same time with their physician and other appropriate staff.  The visit is held in a private area in the practice, such as a conference room.
The visits may include the following components:

• The taking of vital signs;
• An educational piece, such as a 30-minute discussion with a nutritional counselor, dietician, exercise physiologist, podiatrist, or an ophthalmologist;
• A group discussion, during which patients talk with each other about their particular needs, struggles, challenges, lessons learned, and so on;
• And an individual assessment, during which the physician pulls patients out of the group individually for private exams.

"You see these 15 patients in an hour and half, so you're very efficient there," said Dahl. "The other thing that happens is you free up time slots on your schedule to see other patients."
How a group visit is reimbursed.  After the group visit, the practice bills the appropriate visit (99213 or 99214) for each patient that attends. "You don’t bill based on time, you bill based on the criteria for the level of visit they had," said Dahl, noting that documentation must support the level of code.

How a group visit benefits patients. Group visits provide patients with a support group facing similar issues, and they give patients an opportunity to receive more in-depth education about their condition. That often translates to better outcomes, said Dahl.

"You're actually improving patient care, and I say that with some conviction," he said. "The research that’s been done indicates clearly that there’s a positive outcome with patients being more compliant with their treatment plans ... seeking care, getting involved. There are all of these spinoff benefits that come together.

"How a practice can get involved. Assess your patient population to determine if you have enough patients with similar chronic conditions for which a group visit would be beneficial. Then, determine if enough of your patients would participate, said Dahl.

If you determine that a group visit is something you can and should offer, promote it to patients through one-on-one discussions, handouts, and if applicable, on your practice's website or patient portal.

Before the visit, require all participants to sign group-visit specific HIPAA forms noting that they understand that they will be talking about personal health information with other patients, and stating that they will keep the information shared during the group visit confidential.

Article By Aubrey Westgate of Physicians Practice

Do you offer group visits at your practice? What tips would you share with other physicians?

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

Article By G. John Verhovshek, MA, CPC http://www.physicianspractice.com/coding/how-code-negotiate-after-hours-reimbursement-your-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03102013

Update – ACA Increased Medi-Cal Payments for Primary Care Physicians (California MediCaid)

The Department of Health Care Services (DHCS) plans to implement increased fee-for-service Medi-Cal payments for primary care physicians in late October 2013.

 

The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

 

These increased payments are contingent upon pending Centers for Medicare & Medicaid Services (CMS) approval of a DHCS State Plan Amendment (SPA). The increased payments are retroactive for dates of service on or after January 1, 2013.

 

The first interim payment will be issued in October. A final settlement of payment owed but not reimbursed by the interim payment will be issued as early as February 2014.

 

The increased payments are not automatic. Providers must attest to their eligibility, but DHCS estimates that less than half of eligible providers have self-attested. Completing your attestation prior to CMS approval of the SPA and system updates will ensure you receive increased payments as soon as possible. Visit the Medi-Cal ACA Program Page on the Medi-Cal website for more information or to submit a self-attestation form.

 

You should complete your attestation form as soon as possible.

Attestation form link: https://www.medi-cal.ca.gov/acaattest/acaattestmenu.aspx

 

 

Use of Modifier 25 Explained

By Betsy Nicoletti from Physicians Practice

Just the facts, ma'am. It is easy to find both CPT and CMS guidance about the use of modifier 25, and if a group needs "just the facts," the facts are only a few keystrokes away. But if the facts are clear, why does the Office of Inspector General's (OIG) website continue to post notices of physician practices and hospital systems paying back millions of dollars for the use of modifier 25? Do healthcare providers not understand the facts or is there judgment in the interpretation of the guidance in the use of modifier 25?

Let's start with the facts. Modifier 25 is appended to an Evaluation and Management (E&M) service (never to a procedure) to indicate that a significant and separately identifiable E&M service was provided on the same day as a minor surgical procedure. Although I joke that any procedure done on me is a major procedure, a minor procedure is defined as a procedure with zero to ten global days in the CMS Physician Fee Schedule. The catch is the definition of a "significant and separately identifiable." Healthcare professionals often mistakenly believe that assessing the condition and deciding to perform a minor procedure entitles them to an E&M service on the same day as the procedure. This is incorrect.

The National Correct Coding Initiative (NCCI) manual states "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. …If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

"And the CMS manual states that "The initial evaluation is always included in the allowance for a minor surgical procedure."

That is, the payment for evaluating the condition and deciding to perform a procedure is considered part of the payment for the procedure, unless there is a significant and separately identifiable service performed. Do not report a separate E&M service for a planned procedure. Many minor procedures on healthy patients do not require a separate E&M, such as lesion destruction or punch biopsy. The clinician is paid for the evaluation of the lesion as part of the destruction or biopsy. It is permissible to report an E&M service for an unrelated problem or when the problem being evaluated wouldn't necessarily result in the procedure. A patient presents with abnormal vaginal bleeding. The physician assesses the problem prior to deciding to perform the endometrial biopsy. Or, a patient presents with multiple non-healing wounds, and the physician addresses the patient's vascular status, compliance with diabetic regimen, and decides to debride an ulcer. Both the procedure and the E&M may be reported.

So, do healthcare providers not understand the facts or is there judgment in the interpretation and guidance? Both are true. On the provider side, we haven't heeded the statement that the decision to perform a minor procedure is included in the payment for the minor procedure. On the payer side, what constitutes significant and separately identifiable work is not clearly defined. Physician practices might remember this mantra: Using modifier 25 is not always or never, but sometimes. CMS, payers, and the OIG have the use of modifier 25 on their watch lists, so stop and consider whether the E&M service is above and beyond evaluating the site and deciding to perform the service.

Courtesy of: http://www.physicianspractice.com/coding/use-modifier-25-explained?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=05092013

Medicare: Noridian Telephone Reopening Request Guidelines

Beginning September 16, 2013, Part B providers can contact Noridian Telephone Reopening through a single toll free service phone number, 855-609-9960, which includes the Part A and B Provider Contact Centers (PCC), Electronic Data Interchange Support Services (EDISS), Provider Enrollment and User Security.
Telephone Reopenings will be staffed to respond to Part B inquiries Monday – Friday from 6 a.m. – 5 p.m. PT. We will continue to accept telephone reopening requests for items and services Palmetto previously allowed; however, we would also like to inform you of additional telephone reopening services we provide.

Additional Telephone Reopening Services
5 Reopenings per call
Diagnosis additions or changes due to medical necessity (including Local Coverage Determination (LCD) and National Coverage Determination (NCD) denials)
Add modifier AS, 80, 82, 52, 24
Add GV and GW modifier to Hospice claims
Change the MSP type Who Can Request a Telephone Reopening? Physician or supplier Third party authorized by physician or supplier. (Clearinghouse, biller, coder) Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations Complete Claim(s) Research before Calling Reopenings Claim status inquiries call Interactive Voice Recognition (IVR) at the single toll free customer service number. All other inquiries contact Provider Contact Center (PCC) at the single toll free customer service number. If your facility has received an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) indicating that a claim has denied as unprocessable (e.g. MA130 and CO16), it does not have rights to a reopening or an appeal and must be corrected and submitted as a new claim. NOTE: To ensure that the claim in question is truly finalized, wait 4–5 days following your ERA receipt to call Reopenings. Be Prepared When calling Telephone Reopenings the following information must be available when you call. If the following information is not available, you will be referred back to the IVR to obtain the information prior to completing any telephone reopenings. Please remember there’s a limit 5 reopening requests per call. Caller’s name and phone number Provider name and Medicare billing number, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) (individual or group) * Beneficiary’s Medicare Health Insurance Claim (HIC) number * Beneficiary’s last name and first initial* Beneficiary’s date of birth * Date of Service (DOS) Internal Claim Number (ICN) of the claim Billed amount Procedure code (CPT or HCPCS) in question Corrective action to be taken on the claim *The elements with an asterisk must be verified for compliance with the Privacy Act. Corrections (changes/additions/deletions) can be made for the following clerical errors or omissions: Diagnosis additions, changes and deletions Place of service changes Clinical Laboratory Improvement Act (CLIA) Numbers changes or additions Mammography Certification Numbers changes or additions Month/Day of service changes Procedure code changes – up and down code Modifiers additions, changes and deletions Add or change post operative dates Assignment changes (Participating to Non-Participating) Changes that may cause an overpayment (ex. down coding) Change the MSP Type – must match the type and primary insurer on file Add 25 modifier to paid Critical Care (99291-99292, 99298) Prolonged Services (99354-99359) All Psychology codes Initial Preventive Physical Examination (IPPE) Codes (G0402-G0405) Change rendering NPI & PTAN of provider – must be within the same group Ground Ambulance miles changes – up to 50 miles Ground Ambulance (A0428) when billed modifiers HH, RH, NH, EH, SH, PH, HI, and IH Ambulance claims denied duplicate when there were two trips at different times Corrections (changes/additions/deletions) cannot be made for the following clerical errors or omissions: Unprocessable claims Claims that require documentation to make a change (too complex) Year of service Claim line additions and deletions MSP Type changes Recoupment issues Claim(s) with initial determination dates over one year old Erythropoietin (EPO) (J0881-J0886, Q4081) Vertebroplasty (22520-22525) Paravertebral Facet Joint (64493-64495, 64635-64636) Claims paid by another contractor (denial message 610) Modifier additions – GA, GY, GX, GZ, QA, QU, QV, Q1, QJ, 21, 22, 23, 66, and 74 must be requested in writing Air Ambulance Transitional codes 99495-99496 Corrections (changes/additions/deletions) may be made for the following clerical errors or omissions, depending on situation. Units /number(s) of service Modifiers Unlisted procedure codes (if code is on adjudication list, we can adjust) Hospice modifiers May add date span and fractions only (77427, 77336, 77417) Note: Lists included above are not all-inclusive. Reopening Filing Limits Requests must be received by Noridian within one (1) year from the original claim processing date determined by the original Medicare Summary Notice (MSN), ERA, or SPR date. Requests received after the one (1) year time limit will be dismissed as untimely. Good cause for late filing will not be considered over the phone and is not applicable for Telephone Reopenings as described in the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 240. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf   Reopening Timeline Calculator available on the Noridian “Appeals” webpage Type remittance advice date in box Click “Check” button Displays date the request must be received at Noridian CMS mandates that Reopening requests be completed by the Medicare Contractor (Noridian) within 60 days from the date the request was received at the Noridian office. Reopening Determination Notification Approved Determination – An ERA or SPR will contain the payment determination. A separate determination letter for fully favorable reopenings is not sent. Per CMS, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.2, "If a contractor receives a reopening request and does not believe they can change the determination, they should not process the request." Disclaimer: If any of the above requested changes, upon research, are determined to be too complex, the requestor will be notified that the request needs to be sent in writing, with the appropriate documentation, as a Redetermination. Courtesy of: Noridian https://www.noridianmedicare.com/je/docs/telephone_reopening_request_guidelines.html

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

GENERAL PRINCIPLES OF EVALUATION AND MANAGEMENT DOCUMENTATION: If It Isn’t Documented, It Hasn’t Been Done.

“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting.

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time.

Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

• The site of service;
• The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided;    and/or
• That services furnished have been accurately reported.

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services  is appropriate:

• The medical record should be complete and legible;
• The documentation of each patient encounter should include:
•  Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
• Assessment, clinical impression, or diagnosis;
• Medical plan of care; and
• Date and legible identity of the observer.
• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
• Past and present diagnoses should be accessible to the treating and/or consulting physician; Appropriate health risk factors should be identified;
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and
• The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html