AMA CPT® Assistant - 1992 Issue 2 (Summer)
Principles of Documentation (Summer 1992)
Summer 1992 page 21 Coding Clarification Principles of Documentation Editor's Note: The following is excerpted from a brochure entitled "Principles of Medical Record Documentation;" developed jointly by representatives of the American Health Information Management Association, the American Hospital Association, the American Managed Care and Review Association, the American Medical Association, the American Medical Peer Review Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Although the joint development of the principles contained in this brochure are not intended to imply either endorsement of or opposition to specific documentation requirements, all seven groups...
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Article Overview
This article summarizes general principles of medical record documentation and explains why documentation matters for patient care, claims review, utilization review, and legal support. It is written for coders, physicians, and other health care professionals who need a high-level understanding of documentation expectations and how records should support billing and review processes. The piece also includes a checklist-style review of record completeness and a set of broad documentation principles.
Why This Topic Matters
Strong documentation underpins accurate coding, medical necessity review, continuity of care, and claim support. This article provides foundational guidance that helps readers understand what payers and reviewers look for in the record without focusing on a specific procedure or diagnosis topic.
Article Sections
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Coding Clarification
An introductory note explaining the source and context of the documentation guidance, including the organizations associated with the underlying brochure.
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What Is Documentation and Why Is It Important?
A general overview of documentation in the medical record and the broad purposes it serves in patient care, communication, review, research, education, and legal support.
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What Do Payers Want and Why?
A discussion of payer interests in supporting information and the types of general documentation concerns that may arise in review and payment processes.
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What Are Covered Services?
A brief explanation of covered services in relation to benefit plans and the role documentation plays in support of payment.
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What Are Medically Necessary Services?
A general description of how medical necessity is commonly framed and the way that standards may vary by insurer.
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How Does the Documentation in Your Medical Record Measure Up?
A checklist of broad questions used to evaluate whether the medical record supports encounter details, services provided, assessment, progress, and the plan of care.
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Principles of Documentation
A numbered list of high-level documentation principles covering record completeness, encounter content, accessibility of diagnoses, support services, progress, care planning, authentication, and consistency with billed information.
What You Will Learn
- Why medical record documentation is important in health care and claims processing
- How payer review relates to documentation and medical necessity
- The broad elements commonly expected in a patient record
- General principles for evaluating the completeness and supportability of documentation
- How documentation relates to billing records and claim information
Who Should Read This
- Medical coders
- Physicians
- Health information management professionals
- Billing and reimbursement staff
- Utilization review staff
- Medical auditors
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