Medicare Charting Requirements

Medicare requires specific information to be documented on the chart of any patient who files for payment of medical services through the program. These requirements are essential to the processing and paying of claims. The information is used by Medicare to ensure that proper billing procedures are followed. The requirements also help Medicare prevent fraudulent claims.

Ongoing Need

• The need of the patient to continue receiving skilled services must be documented on the Medicare charting forms. It is also required by Medicare that the patient's primary doctor sign off on this documentation. By signing his name to the Medicare chart the doctor is stating that he is in agreement with the care the patient is receiving and verifies that there is a continued and ongoing need for the patient to receive treatment.

Physician's Orders

• The physician's orders are the directions that are provided to the medical staff by the primary doctor or specialist treating the patient. These orders must be recorded and charted for Medicare to review and assess whether the proper charges are being filed according to the orders that were given by the doctor. Billing errors can be found this way. If orders are not recorded on the patient's chart, Medicare may choose to deny the claim all together.

Goals

• Long-term goals for the patient also need to be recorded for Medicare in the patient's chart. This lets Medicare know what the long-term plan for the patient is and how long Medicare may be responsible for paying for the medical bills related to the current condition of the patient. The goals need to be as clear and concise as possible and should provide time frames. Obviously, not all time frames will be met, but it is required to provide a projected amount of time that care will be required. The goals also need to be set in a manner that can be measured. Goals that are vague will be rejected by Medicare and the filing facility will be asked to create new ones.