Reminder: Medical Record Documentation Policy

To support quality member care and ensure our members are receiving medically necessary and appropriate care related to the purpose of their visit, it is Blue Cross Blue Shield of North Dakota’s (BCBSND) expectation that providers submit documentation specific to the patient and specific to the individual encounter. Specific encounter documentation helps ensure that appropriate reimbursement can be determined from the documentation and that reimbursement is not inflated by inappropriate or irrelevant information. It is not expected that every patient would have the same problems, symptoms or would require the same examination and treatment. Documentation should support the individualized care each BCBSND member received.

BCBSND intends to reimburse providers for medically appropriate and necessary services rendered to BCBSND members that treat the condition or concern for which the member is seeking treatment, and for additional concerns or conditions identified during the visit. Documentation without identifiable and appropriate updates specific to the current visit will not be considered for the purposes of determining services provided for that visit.

When documenting the history or exam portion of an evaluation and management (E/M) service, for an established patient office/outpatient visit, if relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed. The defined list of required elements need not be re-recorded if there is evidence that the practitioner reviewed the previous information and updated it as needed.

For the chief complaint and history for new and established patient office/outpatient visits, practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the patient/member. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information. All previous documentation that is reviewed must include the date and time of the visit being reviewed, what information has specifically been reviewed and verified and what, if anything, has changed.

For more information, please see the BCBSND Provider Manual.