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Standards and Guidelines

A patient’s medical record is the historical account of the patient/provider encounter and serves as a legal document for use in legal proceedings. Good healthcare decision making is dependent upon a provider’s ability to retrieve accurate and complete facts from the patient’s record. To assist you in providing proper medical record documentation, here are some helpful guidelines for your reference.

Medical Record Documentation Standards

Samaritan Health Plans submits all Medicare member diagnoses submitted on a claim for the purposes of risk adjustment payments. A patient’s medical record must contain all the necessary documentation to support the services rendered and billed, as well as the medical necessity of those services.

When the appropriate documentation is not included, we may be unable to confirm that payment was made appropriately. This can result in a request for refunds from providers. The Centers for Medicare and Medicaid Services (CMS) will consider the diagnoses submitted as not existing and will request refunds from us.

The rule of thumb is, “If it is not documented, it does not exist.” and, therefore, is not payable. Proper and accurate medical documentation is essential to proper and accurate payment of claims. CPT codes and ICD-9-CM codes reported on the health insurance claim form or billing statements must be supported by the documentation in the patient’s medical record.

Samaritan Health Plans and InterCommunity Health Plans follow Medicare standards for proper documentation, including record retention. All medical records must be maintained for at least ten years after the date of medical services. Proper record retention is important, especially in the event of an audit.