Documentation--Why Bother?

Today, we have a guest posting from Debra Braden, CPC, CUC, HCC Coding Project Specialist in our Risk Adjustment Data Validation (RADV) department.

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Since the advent of the HCC model, documentation has become more important than ever.  Because CMS reimburses for HCC’s they will also conduct audits to make sure the payments were justified.

There are other reasons that documentation is important.  Good documentation can help protect both the patient and the physician.  It is good patient care to clearly document why the patient is having the visit, the conditions they have and what the plan of treatment is.  This aids the current and any subsequent healthcare providers in knowing exactly what is going on with the patient and enables them to monitor and/or treat conditions.  Another important reason is in the case of a malpractice issue.  The court would be able to clearly see what is wrong with the patient and what the physician has done to care for the patient.

In order to pass CMS or Plan audits there is information that should be included in the medical record.  The patient’s name and one other identifier (date of birth, medical record or chart number) should be on every page.  The date of service, legible signature and credentials must be documented.  For a new condition the documentation should include the diagnosis, rationale, any related labs used for assigning the diagnosis and the plan of treatment.  For an established condition the documentation should include the diagnosis, status of the condition and the plan of treatment.

Based on findings from the Medicare Advantage Risk Adjustment Data Validation CMS-HCC Pilot Study several errors were found to be common.

·        Documentation to substantiate the diagnosis code was not in the medical record.

·        Chronic conditions coded but not documented in the report at the time of the visit.

·        Documentation was not in the medical record to support the specificity of conditions.

·        Truncated codes - Not using required 4^th or 5^th digits.

·        Physician unable to locate the medical record.

·        Coding for rule out, questionable or suspected conditions in the office.

·        Coding for acute conditions when the patient was status post or had a history of the condition.

·        Selecting codes incorrectly from superbills.

·        Not coding for documented conditions.

Keep in mind that just because an Electronic Medical Record is used doesn’t mean that it will automatically pass an audit.  Cloning notes from prior visits that a member had with a physician can cause inconsistencies within a note that would make it difficult for a certified medical coder to abstract a particular diagnosis even if it meets the criteria:  a) state the diagnosis, b) show logic or assessment and c) state plan.  Other problems can arise from use of an EMR including the use of an incorrect diagnosis selection lists.  The one thing that EMRs will solve is legibility, but unless intelligent notes are implemented, don’t expect an EMR to help you attain appropriate documentation.

Also keep in mind that good documentation doesn’t mean that the medical record has to be lengthy.  Good documentation simply means that specific information should be in the documentation that shows that a condition was evaluated and/or treated on the date of service.