PRINCIPLES OF DOCUMENTATION of MANUAL MEDICINE ENTRIES FOR CPT

PRINCIPLES OF DOCUMENTATION FOR CPT

• The medical record should be complete and legible. (Ha! Good luck with that!)

• The documentation of each patient encounter should include:
1. reason for the encounter and
2. relevant history,
3. physical examination findings and
4. prior diagnostic tests;
5. assessment,
6. clinical impression or diagnosis;
7. plan for care;
8. rationale for ordering diagnostic and other ancillary services and
9. 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. (Good luck sourcing the following:
1. the consult sheets from the Consultants and
2. getting back the charts from the Prime Attending,
3. Junior Resident, or
4. Medical Records Gophers.

• Appropriate health risk factors should be identified.

• The patient’s treatment plan documentation should include:
1. progress,
2. response to (and changes) in treatment, and
3. any revision(s) of diagnosis(es).

• The CPT and ICD-9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

*Unadulterated Source: CMS and AMA publication BPO-B12, May 1997