Practice Management

Billing, Coding Documentation to Support Services, Minimize Risks

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.5 A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.5 The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.5

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

CMS’ General Principles of Medical Record Documentation6

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For evaluation and management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service, and patient status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

    • reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
    • assessment, clinical impression, or diagnosis;
    • plan for care; and
    • 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-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

References

  1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
  2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
  3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
  4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
  5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
  6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.
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