Doctors deal with interruptions every day. They need to call a patient back. The coding department asks them for clarification on a patient charge. Clinicians and staff come in to talk to them. Although the intention is there, the physician may not document the information in a patient’s medical record due to interruptions redirecting her focus or train of thought.
To complicate documentation issues, today’s physician carries greater burden than in the past. With ICD-10, she needs to specify more details in her documentation, so that the coder is able to code not only for the highest level of specificity, but also for compliance and reimbursement reasons.
Documentation is the physician’s best weapon to maximize both patient care and payer reimbursement. It informs and supports the provider by supplying information to highlight trends and insights into disease processes and unifies physician teams and payers through the continuity of data across visits, hospitals, physicians, and payers.
Remember: Payers determine eligibility for payment through the documentation submitted to substantiate the claim. Providers, therefore, must ensure that their documentation accurately and meticulously reflects a full picture of the encounter. This will, in turn, maximize reimbursement and revenue.
Providers must be able to justify their claims with accurate, timely, and comprehensive clinical documentation. Healthcare professionals rely on the accuracy of correct patient information to create and evaluate treatment plans and monitor patient healthcare over time. It’s imperative that physicians audit their medical records frequently to identify any potential issues before they become a problem.
Good documentation supports:
Pitfall: Undetected problems in medical records can fester, impacting everything that is built on faulty information, including billing for services that may not have been provided. Once payers get involved, physicians can find themselves facing possible fraud and abuse charges — all based on a simple mistake or oversight that snowballed out of control.
Clear Up Confusion with Routine Checks for Quality Control
Linking provider record-keeping to incoming revenue streams is a great feedback mechanism for motivating disinterested providers. If the physician is providing improved documentation, and there is a spike in the revenue received, the coders or practice manager should let the physician know and express their appreciation. Seeing tangible proof of increased revenue underscores to the physician the value of his effort and enhances your credibility, as well.
On the flip side, if the coder has issues with the provider’s documentation and revenue is dipping because of it, the coder should let the provider know. Requests for extra effort and improvement will carry more weight if you support your concerns with hard evidence, such as a drop-in revenue.
Don’t Dig for Details
Providers must appraise not only evaluation and management (E/M) documentation, but also procedural notes. These records serve to account for procedures that occurred and were performed during a particular encounter, like a surgery, for example.
Providers are expected to thoroughly detail the events of encounter, including the date and time, the outcome, and anything unexpected that may have happened and how the care team responded to the crisis. These procedural notes are especially important because faulty or incomplete documentation often results in loss of revenue.
Even if it is implicitly understood by everyone on the care team that a certain procedure always occurs in the operating room during a certain other documented procedure, a coder is still limited to billing only for those services specifically mentioned in the record as having been performed on the patient.
Caution: Auditors for payers do not make inferences into undocumented care they suspect was provided. You’re probably familiar with the phrase, “If it hasn’t been noted in the record, then it never happened.” In other words, a procedure must be indicated and substantiated on the chart and included in the Electronic Medical Record (EMR) for the payers (and auditors) to accept a claim for that service.
If a piece of requisite documentation isn’t there, the auditor will be justified in arguing that the procedure never happened. It’s in the payer’s best interest to save money, so don’t make it easy on them by neglecting to document correctly and thoroughly.
Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.