Is it necessary to leave notes in your patients files to receive payment?

By Suzanne Dorion, VP billing solution of Xacte, a product by PetalMD

Like the majority of your colleagues, you might have been practicing for numerous years without ever questioning the way you maintain your medical records. You should however be aware that your payments could be reviewed by the RAMQ because of your patient’s file.

Although you may have always been paid to date, it only takes one mishandled patient’s file to put you at risk with the RAMQ with regards to your billing or with the CMQ with regards to your practice.

In fact, the absence of a note, without a valid reason, could give the RAMQ reason to believe that the billing code was not done and should therefore not be reimbursed. It is important to be careful with the notion of a “valid reason” and whether to leave a note or not in the file. In fact, in certain cases, the billing code could still be justified despite the absence of a note. For example, would the absence of a note in a patient’s file during the weekend rounds when there is no significant changes in the health condition of a patient be justified in the eyes of the RAMQ? Should you pull out the patient’s file to write “patient is ok” by hand or with a stamp? Would it be this type of unnecessary note that is not justified? I’ll let you be the judge of that. However, what we do know is that we cannot anticipate the RAMQ’s interpretation nor what they will do. It is therefore highly recommended that you leave notes whenever possible!

Your clinical notes as seen by the CMQ and the RAMQ

In the guide, the CMQ explains*:

«Comme le dossier médical est le témoin fidèle de l’état clinique du patient et des actes posés par le médecin, le Collège le considère comme un des outils appropriés pour apprécier la qualité de l’acte médical»

Click here to consult the guide (in French)

Click here to consult more documentation on this topic (in French)

The RAMQ brings back this same notion in its section on investigations and inquiries*:

«Le professionnel doit bien tenir ses dossiers

Les dossiers des patients doivent être bien documentés et respecter les recommandations de l’ordre professionnel. Un dossier doit bien décrire l’état du patient ainsi que les actes pratiqués par le professionnel.

Afin d’éviter toute confusion ou fausse interprétation, les notes cliniques doivent être lisibles et complètes. Des dossiers bien tenus constituent un élément important dans le processus d’analyse de la facturation. Plus un dossier est complet, plus il est utile pour attester les services rendus.

Si les dossiers ne peuvent être présentés à la RAMQ sans raison valable ou qu’aucune note n’y a été inscrite, la RAMQ peut considérer le service faisant l’objet d’une analyse comme n’ayant pas été fourni. Son paiement pourrait ainsi être remis en question.»

Click here to consult the rubric on this topic (in French)

Although the doctor remains fully responsible for his or her billing with the RAMQ, a company specialized in RAMQ medical billing like Xacte can accompany you and answer any questions you may have.

Being guided by experts in your specialty will always be the best way to reduce the risks of being investigated by the RAMQ and to give you peace of mind.

Xacte, 30 years of experience in medical billing

True pioneers in medical billing for 30 years, the team at Xacte has made it their duty to create a product that’s always offering more. The web and mobile versions of Xacte are now currently being used by more than 2,400 healthcare professionals in Québec and are recognized as being the easiest and most powerful tool on the market. Xacte has now joined the big family of products owned by PetalMD, a company specializing in medical technological solutions.

*In order to protect the interpretation of CMQ and RAMQ text, Xacte did not translate it.

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