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Medical Record Documentation

Documentation is the recording of pertinent facts and observations about a patients health history, including past and present illnesses, diagnostic tests, treatments and outcomes. Consistent and complete documentation in the medical record is an essential component of quality patient care. Maintenance of appropriate medical record documentation is also a required component of all provider agreements.

Therefore, all services billed to Blue Cross and Blue Shield of Alabama must be supported by accurate documentation to determine the appropriate benefit application, including: verification that the services were rendered; justification of the medical necessity and quality of the care provided; and validation of accurate claims submissions. The documented services should be reflected accurately on claims by using the Current Procedural Terminology (CPT) codes; Healthcare Procedure Coding System (HCPCS) codes; and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes or descriptions as required.

Services submitted for payment but undocumented in the medical record are unable to be validated and, therefore, ineligible for reimbursement. Additional guidelines for documentation and coverage may be found in our specialty provider manuals (e.g., Chiropractor, Anesthesia, etc.), the Provider Manual (Preferred Occupational Therapist, Preferred DME and Preferred Physical Therapist) and in our medical policies. These resources are available online at www.bcbsal.com/providers. Below is a general list of medical record content and documentation guidelines used for review purposes:

For additional information regarding medical record documentation, please refer to the following resources: