Provider Education & Guides
Dealing with Documentation
Overview
Avoid delays and provide better patient care by submitting fully completed forms with complete and thorough clinical documentation.
➔ Denials can result from missing documentation. If you received a denial code (AUT) for lack of prior authorization, please submit an appeal in response to AUT codes using this form.
➔ Submitting documentation:
Best method
via MyCare portal
Fax
800-781-6260
Mail
Mountain Health Co-Op
PO Box 30311
Salt Lake City, UT 84130
➔ For expedited processing or oral requests for appeals, please call 833-412-4144
Documentation Essentials
Important
Failure to submit required documentation may result in processing delays, the inability to establish medical necessity, and possibly a denial.
Inpatient Admissions Documentation Requirements
✓ Admitting Orders
✓ H&P
✓ ED documentation
✓ Labs
✓ Imaging Results
✓ Medications
Procedure/Imaging Clinical Documentation Requirements
✓ Physician notes
✓ Physical statement
✓ Detailed physical exam on affected site
✓ Radiological findings
✓ Labs
✓ Specific indication and other pertinent information related to the request
✓ NSAID usage
✓ Physical therapy and all other medical modalities tried and their efficacy. Include start and end times.
- medicines
- other modalities
- PT services (for imaging request)
Power or Custom Wheelchair Documentation Requirements
✓ Current wheelchair type
✓ Date of purchase and purchaser (i.e. insurance; private)
✓ Clinical evaluation by patient’s PCP addressing ambulatory ability
✓ Prognosis (in LOMN form)
✓ Wheelchair evaluation by PT/OT within 6 months for clients 21 and older; Shriners and primary Children’s are affiliates within 3 months for under 21
✓ Patient skills check list for power chair
✓ Barriers to transport
✓ Use/accessibility of residents have been addressed
✓ Repair history of current wheelchair (if applicable)
Avoiding Common Issues
Accurate medical documentation is key to successful claims submission.
Improper documentation of a single patient can mean a difference of about $10,000 a year or more.
Clinical documentation is essential for inpatient medical care. Medical documentation with deficiencies can cause all sorts of issues. Insufficient documentation can cause claims to be down-coded or denied, cause retraction of previous payments, or flag practice for prepayment review.
Pro Tip
Be sure that your coding is compliant.
Incorrectly linking CPT, ICD -CM, and HCPCS level 2 codes can hurt reimbursement. Follow all coding guidelines for your billing. See more coding guidelines.
Small errors can often add up the dollars of the revenue missed.
ⓧ Physician orders/scripts are missing, incomplete, outdated, or illegible.
ⓧ Date of service is wrong or missing
ⓧ CPT/ HCPCS level II modifiers are missing or wrong
ⓧ Missing clinical / medical necessity
ⓧ Unspecified diagnosis conditions or missing severity of the condition
ⓧ Undocumented procedures
ⓧ Patient encounter details are missing
ⓧ Cloned documentation
ⓧ New vs. Established patient details
ⓧ Commonly missed charges
- supplies
- devicies
- injections
- infusion
- vaccines
- venipuncture