Confessions of medical records ‘experts’

March 18, 2013

Edited by Chuck Brownlow, O.D., Medical Records consultant, AOAExcel

There seems to be an abundance of people around health care calling themselves “experts” or who are referred to by others as “experts.”

As consultants, we think it’s time we “come clean” and provide our impression of what an “expert” really is.

First, since our area of interest includes issues related to medical record-keeping and coding, let’s investigate what an “expert” in this area has that others may be lacking.

1. Interest—In order to learn anything, one must first be interested. With respect to medical record-keeping it seems many health care professionals believe they can provide care and keep records without knowing or complying with the rules related to medical records. A consultant or expert in this area, whether she or he really wanted to be or not, first had to develop an interest in learning more.

2. Resources—Medical record-keeping has national standards that make it pretty straightforward to develop an understanding of what constitutes good medical records and what is required to choose procedure, office visit, and diagnosis codes accurately. All of the necessary resources and references are readily available and actually quite inexpensive, especially when compared to the fines and repayments that can result from not being familiar with the rules related to medical records.

The three key resources are:

  • Current Procedural Terminology* (CPT © American Medical Association),
  • International Classification of Diseases, 9th Revision, and
  • The Documentation Guidelines for the Evaluation and Management Services, 1997, (rules for choosing 99000 office visit codes).

Fortunately for AOA members, these references are available as a two-volume set through the AOA Marketplace, as AOA Codes for Optometry ($145), www.aoa.org/onlinestore. AOA members and their staff may also access www.aoacodingtoday.com for information related to Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes, and find many resources available at www.excelod.com/coding.

*The American Medical Association (AMA) CPT is the only official CPT. There are “substitutes,” but you must have the AMA CPT, as its definitions are the only ones nationally recognized and required by Health Insurance Portability and Accountability Act (HIPAA) for use by health care providers and insurers.

There…that’s it. If you have the interest and you have the resources and references, you are well on your way to being an “expert” in the area of medical record-keeping and accurate procedure, office visit, and diagnosis coding.

Wait. There is one more important necessary element to becoming familiar with the rules for medical records and coding…

3. Motivation—It’s clear that doctors and staff must be motivated in order to develop the interest and to seek out and use the resources. Sadly, the third element, motivation, may finally arise in health care practices because of the looming threat of audits of medical records and claims by Medicare contractors and by other insurers.

All provider agreements include a stipulation permitting the insurer to audit doctors’ records related to claims for payment.

These audits are all based on the resources listed above, so keeping records based on those resources prepares physicians for doing well in audits.

There is no alternative now. Every physician and all staff involved in medical records, coding, and preparation and submission of claims must be accurately applying the rules for medical records and coding. They must be “experts” for their own practices.

As consultants in these important areas, often accused of pretending to be “experts,” we “Codeheads” urge optometrists and key staff to develop the Interest, to purchase and utilize the Resources, and to respond positively to the Motivation to become “experts” yourselves…You will be glad you did!

One comment

  1. Great Article Chuck. You make the Codeheads Proud.

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