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Julie Taitsman, Chief Medical Officer for OIG, gave a presentation recently as a part of OIG’s award-winning Health Care Fraud Prevention and Enforcement Action Team (HEAT) entitled, The Importance of Documentation. Taitsman’s presentation can help you to better understand the issues surrounding proper medical records documentation in patient medical records and in Medicare claims and bills.This blog post is the second of a two-part series on the topic.This practice brief provides guidance for maintaining documentation integrity while using automated EHR functions.Documentation integrity involves the accuracy of the complete health record.

In a post-payment review of claims not supported by documentation of the medical record, CMS may, at the very least, require that the provider repay Medicare and Medicaid for the money that was received.However, the OIG has also reviewed imaging records that contain little more than the patients’ names, a chief complaint and some vital signs.In one example, no information was recorded about the service performed that Medicare was billed for, other than the letters CXR, indicating that the patient got a chest x-ray.You can read The Importance of Documentation for Medicare and Medicaid Claims, Part I now.Accurate Records Protect Providers If your medical records are selected for review, clear records will help you to withstand scrutiny.

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