By: Marge McQuade, CMSCS, CHCI

With ICD-10 now being put off for another year, now is a good time to look at some of the basics of documentation that are needed to code correctly, especially since recently everyone had been concentrating on documenting correctly for the new ICD-10 codes. 

An appropriately documented medical record can expedite claims processing, reduce errors, and may serve as a legal document to verify the care provided.  The medical record should be complete and legible, utilizing widely accepted and recognized abbreviations and symbols. It should also be dated and authenticated (signed) by the physician. Documentation should support the intensity of the evaluation and/or treatment, including thought processes and the complexity of medical decision-making.