Reminder: Follow documentation guidelines for physician office infusion therapy

To avoid potential recoveries, please be sure patient medical records correctly document physician office infusion therapy visits.

Blue Cross Blue Shield of Michigan requires you to follow its Documentation Guidelines for Physicians and Other Professional Providers. Our auditors use these guidelines to ensure the services, treatments, procedures and devices billed to us were provided in accordance with the provisions of your participation agreement. This means they were medically necessary, ordered by the physician, provided to the patient and documented in the medical record.

Electronic documentation and electronic signatures are accepted; however, it’s important medical records accurately describe the services performed.

Please remember the following:

• Handwritten changes applied to printed electronic medical records, such as writing over or crossing out without initialing, or any changes that make the documentation difficult to interpret will be considered illegible.
• All printed EMRs must be complete and properly identify the patient. The services provided during the visit must be described in the record and meet Current Procedural Terminology coding guidelines and BCBSM documentation guidelines.
• All staff involved with the patient prior to, during or after the encounter is responsible for documenting the services provided. The records must be dated and signed or initialed with the credentials of the person who performed the service.
• Verbal orders obtained by the office staff must be written, dated and signed or initialed by the staff member with his or her credentials, as well as dated and signed or initialed by the ordering physician.
• When administering an infusion, you must record the start and end time of the infusion as specified in the CPT manual. Only stating the total time of the administration is not permitted — for example, “20 minutes” is not sufficient.
• Any changes made to the printed EMR must be updated in the actual electronic record.

By providing this vital information, you can avoid potential audit recoveries by BCBSM.