Why proper documentation is vital

June 27, 2023
And how to ensure a patient’s medical record is properly documented.
Optometrist at computer thinking

Excerpted from page 46 of the May/June 2023 edition of AOA Focus

Written by the AOA’s Coding & Reimbursement Committee

Properly documenting a patient’s medical records has always been important. However, it has never been more important than now, given today’s health care landscape where the government ties reimbursement to the quality and content of the provider’s documentation of the patient’s medical record. This is not only required for error-free coding, billing, claim submission and defense of chart audits with insurance companies but also for avoiding malpractice lawsuits.

A defense against malpractice lawsuits

Although malpractice lawsuits are relatively rare in optometry vis-à-vis other specialties, they can still wreak a disastrous disruption on an optometry practice’s cash flow, as well as damage the reputation of the doctor of optometry. After interviewing a potential malpractice plaintiff, one of the first things a malpractice attorney does is secure the medical record and submit it to an expert for review. A fully documented record can forestall a lawsuit. In the event of a claim of injury or neglect, a poorly

documented record can lead an attorney to pursue a claim aggressively. Full and proper documentation potentially provides proof that the doctor of optometry did the right thing and supports the idea that they are a careful and caring physician who gave adequate thought and consideration to the case. 

Ensuring accurate and adequate reimbursement

The COVID-19 pandemic brought various challenges related to health care reforms, increased federal scrutiny and rising costs. Now, more patients than ever before are visiting doctors of optometry with eye-related diseases. Doctors of optometry are getting busier due to an increase in eye diseases and the aging American population. In 2020, 111 million refractive eye exams were performed in the U.S., 85% of which were performed by doctors of optometry, according to an article in the Journal of Ophthalmology. The need for better record documentation has been compounded by the fact that the optometric scope of practice is growing significantly in many states.

Furthermore, a shift toward value-based care has ushered in drastic changes to reimbursement schemes. For example, in recent years the Centers for Medicare & Medicaid Services (CMS) has significantly changed the exam and documentation criteria for the 992xx E/M codes. Along with other major payers, they also increased the reimbursement for the E/M codes, which has led to them exceeding the reimbursements of the 920xx codes for new and established patients.

These changes underscore how vital it is for doctors of optometry to properly and thoroughly document patient visits to show medical necessity for the visit in addition to a well-thought-out assessment and plan for a patient’s care. To keep things aligned with current health care reforms, optometrists must properly document pertinent medical history and important clinical findings during the initial checkup, and properly archive the treatment plan of the patients, laboratory tests, and results. Such measures are vital for the following reasons:

  1. Proper documentation improves the continuity of patient care and enhances communication with the care team.
    A well-documented patient record clearly and officially expresses how a patient was treated and the reasons for that treatment. This facilitates the best possible treatment for the patient and allows other members of the patient’s care team to understand the patient’s history.
  1. Proper documentation decreases the likelihood of a successful malpractice lawsuit.
    Thorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim. A well-documented record serves as evidence of treatment and care, helping to alleviate liability concerns in the event of a claim.
  1. Proper documentation records CMS quality indicators and measures.
    With the current shift toward value-based care, the federal government is asking doctors of optometry and other specialists to report metrics that enhance the epidemiology of public health and create better value for patients. These include Merit-based Incentive Payment System measures and the social determinants of health as applicable.
  1. Proper documentation ensures appropriate reimbursement.
    A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any obstacles associated with claims processing and ensure appropriate reimbursement.

What should doctors of optometry do?

To ensure a patient’s medical record is properly documented, doctors of optometry should adhere to the following:

  • The patient record must uniquely identify the individual with biographical information.
  • The patient record must identify the name of the person providing care and the date of service.
  • The patient record should contain an appropriate medical history including medications, conditions presently treated and the social determinants of health, which may impact the care of the patient.
  • The chief complaint and reason for the visit should be clearly stated and expanded as needed.
  • An appropriate physical examination based upon the needs of the patient should be documented.
  • Laboratory and diagnostic testing that has been ordered or completed should be documented with a report.
  • A diagnosis should be formulated as well as a treatment plan consistent with the diagnosis or clinical needs of the patient.
  • Prescription and medication orders are clearly written and legible.
  • Orders for additional testing or consultations should be properly drafted.
  • Proper ICD-10 diagnosis codes and CPT procedure codes are listed, which correspond to the physical examination, testing, diagnosis and treatment plan.

In conclusion, clear and concise medical record documentation is critical to providing patients with quality eye care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping doctors of optometry evaluate and plan the patient’s treatment and maintain the continuum of care.

AOA’s Medical Records and Coding Service

A member benefit designed to educate doctors of optometry and their staff members on the proper documentation of medical records, compliance and coding.

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