Documentation and Audits: The Dynamic Duo

Clear and concise documentation in the medical record is essential for many reasons. For physicians, it is their way of knowing, clinically, what is happening with the patient. For payment purposes, it is the itemized invoice for the insurance company to indicate the services provided in a detailed manner. The decision for payment to be made is based on the medical necessity of a service. Unfortunately, if a service is not documented well, the insurance company will consider the service “not medically necessary.” The reason or thought process for each service provided must be documented clearly to indicate why the service is necessary.

Correct Documentation Supports Medical Necessity
Medical necessity is the driver for the type and level of service that should be billed. Because the Evaluation and Management (E/M) guidelines are complex and subjective, it is easy for providers to utilize a template so that notes are documented the same way each time they see a patient. This may provide a false sense of security that they are accurately coding their services on a consistent basis. The problem is that not all patients require the same level of care at every visit. Only services that are required to treat the patient’s problem that day should be provided.

A child who comes in with a cough and a runny nose, without a fever or other symptoms, may be diagnosed with an upper respiratory infection. If that same child came in with a croupy cough with a fever, and was having a hard time with shortness of breath, the physician may be concerned with the possibility of pneumonia. This probably would cause the physician to order a chest x-ray, as well as to perform some lab tests. By documenting the thought process or concerns for the second example, it is clear that there is a greater risk to the patient’s well being if the problem was not treated.

Much of the work physicians do is not documented in their note because they feel that another clinician looking at the note would understand things that are “inferred.” But many different people, not just clinicians, review the note. Often, coders do not have clinical backgrounds; therefore, details must be clear to the non-clinical person, as well. Providers often feel this takes away from their note. Keep in mind that medical documentation serves many purposes and one of them is to tell the story clearly of what is happening with the patient, and why the provider performed the work they did in each specific instance.

“Convenient” Isn’t Necessarily Necessary
Insurance companies will only pay for services provided to their beneficiaries that are specifically required for each service, based on the patient’s chief complaint or additional conditions that require work-up or focused attention. Services provided out of “convenience” for the patient will not be considered medically necessary because the patient did not have any specific complaints relating to the service. This often happens in specialty practices with subspecialists within the same group practice.

For example, in an ophthalmology practice, the patient comes in to see the general ophthalmologist. Because he has traveled 3 hours to get to the clinic, he also will see the cataract specialist, the retinal specialist and the glaucoma specialist. The patient did not have any complaints — rather, the patient had seen these providers in the past and it was felt that he should be “checked on” while he was in the office. In other words, the services were not medically necessary.

At first, this may seem ludicrous; however, if you were to think about it from the payer’s perspective, you would wonder why the general ophthalmologist cannot “check on” all areas of the eye. If a problem is then identified, then medical necessity has been identified and a second visit may be arguable to an insurance company. There is immense potential for excessive fraud and abuse in allowing these types of services to be reimbursed at an unlimited capacity.

Auditing Assures Quality
To ensure documentation clearly supports services provided, consistent recurring audits should be performed. There are a variety of ways that chart auditing can be accomplished.

Internal auditing is cost effective because there usually is one person or department who has this specific task to perform on a regular basis. Problems can arise when the providers feel very comfortable challenging the employee because they do not feel the employee has the appropriate training or depth of knowledge that an outsider may have. Many practices invest in their employees to obtain additional and/or ongoing training to make sure the employee stays up to date on coding changes.

You can hire an outside source to perform an audit for you, although the cost can be a significant disadvantage for some practices. You should consider, however, that an outside auditor often can complete audits on a more timely basis because they are not focused on other responsibilities in the office. This likewise allows the office staff to focus on patient care and other billing/coding functions.

Stay Current
Because rules and regulations change periodically and vary by payer, it is imperative that coders, providers, and auditors consistently stay abreast of the changes. The Centers for Medicare and Medicaid Services (CMS) has been the leader in publishing rules and regulations. All payers can create their own individual policies; therefore, it’s important for physicians’ offices to become familiar with each of their individual payers policies and contracts regarding reimbursement.

Rules not only vary based on payer, they also can vary based on region. CMS is the national governing body for Medicare; however, there are local carriers assigned to different regions. Each region has a different way of auditing and assessing documentation. Specific information for each region generally is easy to find on the local carrier’s website.

Focus Education on Proper Coding, Not Upcoding
One area that can be very tricky is the difference between educating the providers and “leading” them to add documentation that may not be completely necessary, but that would allow them to bill for a higher level of service.

Education comes from reviewing the guidelines and providing feedback and examples of the different types of patients that would fall into the various levels of service. As in the examples above of the child with an upper respiratory infection (URI), the first example may document out to a level three; however, the second example clearly requires more work and increased risk and medical decision-making. It may be tempting to code all URIs to a level four if a prescription is given; however, the nature of the presenting problem also must support billing the service at a level four. Most payers would not agree with coding a level four E/M service solely because a prescription was given. Again, if the thought process were documented, it would be more apparent that additional work was required for a sicker child.

The best way to ensure a positive outcome from an audit is to invest in the education and coding skills of all coders in the office. Ongoing education and networking with other coding professionals is very beneficial in keeping current on the ever-changing rules of coding. If that is not a viable option for a practice, then it would be most advantageous to hire an outside source to conduct audits and provide training to all staff. Generally, outside agencies have greater resource bases to ensure changes and trends are followed consistently. Whatever option is chosen, be sure the office is open to communication and education to ensure services are billed appropriately.

Kim Reid has more than 20 years of experience in the health care industry. As a senior coding educator for Fletcher Allen Health Care in Vermont, she specializes in the areas of surgery, pediatrics, neurology and psychiatry. She is an approved PMCC instructor for American Academy of Professional Coders. Reid has coordinated local coding development seminars, basic and advanced coding classes, and workshops through the AAPC, and has served in as both president-elect and president for the Burlington, Vermont AAPC Local Chapter.

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