You are accountable for ensuring accurate health record documentation.
No chiropractor has ever exclaimed, ‘More documentation, yes!’ The task of health record documentation stands out as the most challenging (and often unrewarding) aspect of being an effective doctor. The primary advantage of thorough documentation in healthcare is its potential to enhance the quality of patient care. With a patient’s complete history readily available, doctors can make more informed decisions regarding diagnosis and treatment.
In our roles as compliance specialists, especially when addressing audits, we frequently encounter various explanations for missing or incomplete documentation, typically stemming from a lack of familiarity with the regulations. This article highlights the most prevalent errors we come across and offers guidance on how to avoid them
The documentation fails to establish the medical necessity
Providers must first grasp the distinction between care that aligns with their clinical expertise and scope of practice, and care that is deemed medically necessary by an external party.
Clinically appropriate care is focused on enhancing quality of life, alleviating symptoms, and fostering overall well-being. It encompasses all recommended care, including supportive or maintenance measures. On the other hand, medically necessary care adheres to a more stringent standard, with its definition varying depending on the payer type or even the provider’s licensing board.
Some may adhere to Medicare’s guidelines, necessitating documented evidence of a spinal subluxation leading to a neuromusculoskeletal condition. Others may allow practitioners to diagnose and treat patients within the bounds of their scope of practice. For care to be deemed medically necessary, the patient must have a significant health condition requiring treatment with a reasonable expectation of improvement in their condition. Additionally, treatment should have the potential to enhance the patient’s functioning.
The most effective means of substantiating medical necessity lies in the provider’s documentation, encompassing initial intake, history, examinations, daily treatment notes, a treatment plan featuring measurable functional objectives, and appropriate imaging when necessary. When medical necessity is confirmed, it is referred to as active treatment. Failing to meet this criterion categorizes patient care as maintenance, supportive, or wellness care—clinically appropriate, but not medically necessary. The majority of third-party payers solely reimburse for active treatment. To guard against this oversight, it is crucial to understand the specific definition of medical necessity set forth by the third-party payer, typically outlined in their medical review policy or related documentation
The coding in CPT and ICD doesn’t align with the documentation.
Documentation and coding are intricately linked, with coding needing to be based on the documentation rather than the other way around. Unfortunately, it’s common for providers to choose a code to describe a service or condition without ensuring that the documentation supports its use. This practice has led to audit failures and has negatively impacted our profession’s reputation in terms of proper documentation.
A notable example arises when a provider addresses the entire spine, encompassing all five spinal regions, while the patient presents with a singular complaint in the neck. While it may be clinically appropriate to adjust compensatory areas related to the neck pain, billing for 98941 (3-4 spinal regions) or 98942 (5 spinal regions) is simply inaccurate when the focus of complaints and findings is solely on the neck. Providers should prioritize documenting the complaints and issues, billing only for the areas that are medically necessary.
It is essential to ensure that each complaint from the patient’s history is substantiated in the examination. If there are findings in an area without a corresponding complaint, it’s crucial to verify with the patient and incorporate this information into the consultative notes in the history to justify treatment in that region. Additionally, each area should have a proper diagnosis, and the patient’s treatment plan should encompass all necessary treatment for each billed area.
Absence of Documentation
According to the regulations, billing cannot be submitted for any service that lacks proper documentation or a valid provider signature on the note. Unfortunately, this violation occurs far too frequently. In one case, a provider sought assistance after receiving an audit notice spanning three years of records, only to discover that no patient records were maintained during that period. Regrettably, during a divorce, their soon-to-be-ex-spouse exploited this knowledge and reported the provider as a bargaining chip. There is no legitimate defense for billing an undocumented service.
Hence, it is imperative to adhere to fundamental best practices in documentation. Malpractice carriers strongly advise obtaining written consent for treatment when applicable. All patient entries should be promptly recorded, ideally during or shortly after a visit, and dated to maintain chronological accuracy. Medicare defines contemporaneous documentation as within a 24-hour window. Implement checks and balances to ensure all notes are comprehensive and signed before submitting them for billing.
Experimental, Investigational, and Unproven Procedures and Techniques
Determining whether techniques like NUCCA or therapies like laser and dry needling are considered experimental can often depend on the entity making the rules, such as your state board of examiners or the third-party payer you’re billing. While these techniques can be highly beneficial for patients, they are sometimes labeled as medically unnecessary, experimental, investigational, or unproven. This doesn’t mean you can’t provide the service within your scope of practice (as long as it’s clinically appropriate, as mentioned above), but you must be aware of the specific documentation requirements for these techniques and services.
These types of services usually necessitate prior notification to the patient and documented acknowledgment that the patient understands the service’s status and is willing to cover its cost themselves. This critical information can be found in your compliance arsenal’s most important document: the medical review policy (MRP) for the service you’re providing and the payer you’re billing. Familiarize yourself with these restricting regulations and document accordingly. Additionally, certain boards, like the one in Colorado, may require an additional notice of patient consent for these types of services.
Lack of Provider’s Signature and Authentication
Surprisingly, we do encounter instances where providers fail to sign their notes, and this is a cause for concern. With electronic health record (EHR) software, signing the note often equates to closing it out. A common oversight occurs when the note is never properly finalized. Consequently, when records are requested, we find that they haven’t been reviewed to ensure all details are finalized.
As per the Centers for Medicare and Medicaid Services (CMS), services cannot be billed if the provider’s note is not signed. Often, rectifying this issue may be as straightforward as adjusting a setting in the software. We strongly recommend routinely reviewing all records at the end of a shift or day to confirm that any team member involved in the care and note writing has appropriately indicated their involvement, and that the supervising provider has signed off on the note.
If you come across a medical record note or order lacking a signature, all is not lost. An attestation can be submitted to verify the authorship of the note. Additionally, if a note is signed after the fact, it’s advisable to include an addendum explaining the reason, along with the new signature and date. Generally, records should be signed within 24 hours of the service.
Remember, documentation need not be a burdensome task. It forms an integral part of the patient’s expectation of care in your office and is one of the business responsibilities of licensed healthcare providers. Health record documentation is a component of compliance and an essential aspect of practice. Endeavor to consider these pitfalls and commit to continuously enhancing your documentation practices. An improved level of compliance often leads to an enhanced bottom line.”