E/M Coding Alert - 2016 Issue 8
Documentation: Polish Your Recordkeeping Skills to Face Any Kind of Review
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Article Overview
This article is a documentation-focused compliance guide for medical coding and billing teams. It explains why record clarity matters during review, discusses general concerns around abbreviations in medical records, and addresses documentation signature expectations when a scribe participates in the encounter. The content is most relevant to coders, auditors, compliance staff, and providers who want to strengthen chart support without running afoul of payer documentation standards.
Why This Topic Matters
Documentation quality can influence whether submitted claims are supported during review. Clear records, standardized terminology, and proper authentication help practices prepare for audits and reduce avoidable documentation problems.
Article Sections
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Legibility of medical records
This section addresses why readable clinical documentation is important for audit support and discusses general ways providers may improve record clarity.
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Abbreviations in documentation
This section covers concerns about abbreviation use in medical records and emphasizes the importance of standardized terminology.
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Scribe documentation and signatures
This section discusses documentation involvement when scribes are used and highlights signature/authentication considerations for the record.
What You Will Learn
- Why documentation legibility matters in a review setting
- General concerns associated with abbreviations in medical records
- What to consider when scribes are involved in chart documentation
- How documentation practices relate to audit readiness
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Physicians
- Practice managers
- Auditors
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