1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
   • The reason for the encounter and relevant history, physical examination findings and prior diagnostic test results
   • Assessment, clinical impression or diagnosis
   • Plan for care
   • Date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient's progress, response to and changes in treatment and revision of diagnosis should be documented.
7. The CPT and ICD-10-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
8. When documenting your review of systems, it is acceptable to use the statement "All others negative" or "No other complaints" as long as the pertinent systems/symptoms/problems were addressed and documented.
9. The review of systems and/or past family and/or social history may be recorded by ancillary staff or on a form completed by the patient. To document that the physician or other health care provider reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
10. The chief complaint should be clearly stated in the documentation for each encounter. The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the encounter. The chief complaint is usually a statement in the patient's own words. A chief complaint is usually not a follow-up or office visit.

Errors in billing can be caused by many factors such as human error, coding errors, out-of-date management software and unverified patient information. Take time to verify insurance information each time the patient comes into the office. Train all staff to verify patient's name, address and policy numbers in order to avoid denied claims. Remember providers and office staff need to work together as a team. Routinely check the Explanation of Benefits to see why a claim was not paid. Some claims denials can be caused because a modifier was left out or numbers in a CPT code were transposed. Make sure that staff are continually educated and up-to-date on all the changes in coding to ensure clean claims billing. Accurately documenting a patient encounter is essential for correct billing and reimbursement.