Documentation & Reimbursement Q&A

Elite Learning recently interviewed Kathleen D. Schaum, MS, president of Kathleen D. Schaum & Association Inc., Lake Worth, FL, about how healthcare providers can exercise documentation best practices to receive appropriate reimbursement and protect themselves and their businesses should an audit occur.

In your opinion, are most healthcare providers documenting appropriately to support the medical necessity of the care they are giving? 

Although all healthcare professionals are taught that, “If it is not documented, it is not done,” many often do not appreciate the importance of this teaching. In their day-to-day work, they are so busy caring for patients that they may skimp on their documentation. If their claims get paid despite incomplete documentation, these healthcare professionals often continue to document as little as possible. Then, when they undergo audits, they wish that they had taken the time to document as if the medical record was their only method of communication. In fact, most payers report that lack of documentation or inadequate documentation is always one of the top reasons for claim denials and repayments. 

Please describe the challenges associated with properly documenting one’s care in relation to medical necessity. 

Physicians and other qualified healthcare professionals (QHPs) cite many reasons for not documenting completely, for example, lack of time, belief that payers will still pay them if they code correctly, cumbersome electronic health records (EHRs), etc. Unfortunately, these reasons do not help them participate in coordination of care across the continuum of care, meet the Triple Aim goals established by the Institute for Healthcare Improvement, obtain a risk-adjustment factor score that describes just how ill their patients are, achieve a high-quality-of-care score, pass pre-payment and post-payment audits, etc.   

Physicians’ and other QHPs’ documentation should “paint the picture” of each patient’s condition and the work performed at each patient encounter. The documentation should minimally include:

  • Current problem(s) and medication(s) list
  • Specific sign(s), symptom(s), or patient complaint(s) that make the service(s), procedure(s), and/or product(s) reasonable and necessary
  • Plan of care
  • Medical necessity for the service(s), procedure(s), and/or product(s)
  • If multiple medical options exist, a detailed rationale for the specific option selected
  • Signed order for the service(s), procedure(s) and/or product(s). The signature must be legible and may be handwritten or electronic. Stamped signatures are not acceptable. 
  • Complete description of all services/procedures provided
  • Follow-up care assessments, test results, additional services/procedures 

When regulations and/or coverage policies exist for specific services, procedures, and/or products, physicians/QHPs should take the time to read these guidance documents and to design their documentation templates to address every required component. Unfortunately, many physicians/QHPs believe that these documents should be read by their coders and billers. They fail to realize that these guidance documents are their “playbooks.” Auditors use these same guidance documents when they conduct audits. They look at each of the required documentation elements. If one (or more) required element is missing, the claim is denied, or repayment is requested. Physicians/QHPs can easily prevent these denials and repayments by taking the time to learn about the regulations and specific medical-necessity criteria outlined in Medicare’s national coverage determinations (NCDs) and local coverage determinations (LCDs) for the services, procedures, and products they perform and/or order.

In your opinion, are most healthcare providers accurately describing the work performed at the site of care within their documentation to receive the correct level of reimbursement? 

I wish that I could answer this question positively for all healthcare professionals. Of course, some healthcare professionals have fabulous documentation in their EHRs that are laid out in an easy-to-find and easy-to-read format. Unfortunately, other healthcare professionals do not know what “correct documentation” looks like and/or do not wish to take the time to document completely. In those cases, both the healthcare professional and the facility are in jeopardy of incorrect payments. 

What would you say are the most common mistakes that providers tend to make in relation to their documentation? 

  1. Not documenting the primary, secondary, and comorbidities that are addressed in their medical decision-making for the encounter. I receive numerous telephone calls per week, during which the healthcare professional asks “Which diagnosis code should I put on my claim so the claim will be paid?”
  2. Not documenting a plan of care that includes: 
  • Treatment goals
  • Accurate accounting of all diagnostic tests
  • Physician follow up
  • Complicating factors 
  • Measures taken to control complicating factors
  • Physician reassessment
  • Not documenting the current care
  • Not writing orders for all services, procedures, and products performed and/or ordered

Are there specific modalities that are more challenging to document that providers and their practices should be extra cautious about? 

Specialists (and their facilities) who perform surgical and medical procedures face many challenges. They must explicitly document the patient’s condition, the conservative medical care that was tried or contraindicated, diagnostic test results, a full description of the procedure that meets the requirements of NCDs, LCDs, and the directions included in package inserts, etc. 

In your opinion, are most providers/practices receiving the appropriate amount of reimbursement in relation to the work that they/the practice are performing?

This is a difficult question to answer across the board. Consider the following, for example:

  • Some healthcare professionals document and code impeccably and receive the correct reimbursement.
  • Some healthcare professionals document poorly, code impeccably, and receive the correct reimbursement, but often incur claim denials upon pre-payment audits and/or repayments after post-payment audits.
  • Some healthcare professionals document and code poorly and receive the incorrect reimbursement.

How might a provider/practice be able to assess whether their staff/practice is appropriately documenting?

All healthcare professionals and providers should conduct internal audits on a regular basis. Before conducting the audits, they should make a checklist of the documentation requirements of regulations for coding and for coverage that pertain to each service, procedure, and product that was ordered and/or performed. If all the items on the checklist are clearly documented, the internal auditors should praise the healthcare professionals who excelled. If all the items on the checklist are not clearly documented, the internal auditor should take the time to educate the professionals on how to improve their documentation and then re-audit them to see if they improve. 

During internal audits, verify that your EHR presents the information in a clear, concise format that paints the picture of the patient’s condition and the exact care that was provided.

What are the steps that providers can take immediately to improve their documentation, even if they believe their documentation is perfect?

If a healthcare professional believes that his or her documentation is perfect, that is awesome. In those cases, they should have a semi-annual audit by certified coders who specialize in auditing the services, procedures, and products that are ordered and/or performed by that healthcare professional. Because regulations, NCDs, and LCDs change frequently, the auditor should be able to identify areas of improvement that the healthcare professional may not even realize are required. 

Additionally, all healthcare professionals should:

  • “Paint a picture” of the patient’s condition and their professional work in the medical record
  • Provide communication that can be used as the patient moves throughout the continuum of care
  • Document as if every episode of care will be entered into litigation
  • Ensure that codes submitted on claims are supported with documentation
  • Document to support quality measures that are reported
  • Verify that documentation is collectable and reportable for research purposes

Are there any changes related to documentation and/or coding that providers/practices should keep on their radar?  

All healthcare professionals need to pay attention to the documentation required to justify medical necessity for their work. This requires understanding the specificity of diagnosis codes that represent the primary and secondary diagnoses, as well as the comorbidities that must be considered when treating the primary and secondary diagnoses. The documentation must address each of the pertinent diagnoses. For years, many healthcare professionals thought that correct diagnosing and diagnosis codes only mattered to acute care hospitals. Nothing can be further from the truth. All professionals and providers must document medical necessity. In fact, home health agencies and skilled-nursing facilities are embarking on new Medicare payment systems that requires them to focus on the patients’ diagnoses more than ever. 

All healthcare professionals who bill for evaluation and management services should keep their eyes open for the new coding guidelines and documentation regulations that should be released later next year. 

Kathleen D. Schaum is president of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. She can be reached for questions and consultation at k[email protected], or by calling 561-964-2470 or 561-670-7176

Disclaimer: Documentation, reimbursement, and coding information can quickly change. It is up to individual healthcare providers to ensure accuracy of their documentation. This content is intended for general information purposes only. 

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