Correct health record documentation is your responsibility
“MORE DOCUMENTATION, YES,” said no chiropractor ever. Health record documentation is the most difficult (and unrewarding) part of being a good doctor. The most important benefit of documentation in health care is it can improve the quality of patient care. When doctors have the patient’s complete history in front of them, they can make better decisions regarding diagnosis and treatment.
As compliance specialists, and when defending an audit, we hear many reasons the necessary documentation was missing or incomplete, and they are usually related to ignorance of the rules. This article provides the most common errors we see and how to avoid them.
Documentation doesn’t establish medical necessity
First, providers must understand the difference between care that is clinically appropriate and aligned with your scope of practice, and that which is deemed medically necessary by a third party.
Clinically appropriate care is care that enhances life, relieves symptoms and promotes wellness. It may be supportive or maintenance care and encompasses all the care you recommend. But medically necessary care meets a higher standard and definition, which varies based on the payer type or even your board of examiners.
Some may follow Medicare’s guidelines and require a documented spinal subluxation causing a neuromusculoskeletal condition, while others may allow doctors to diagnose and treat patients based on their scope of practice. The patient must have a significant health condition necessitating treatment with a reasonable expectation of recovery. The ability to improve the patient’s function through treatment is also a requirement.
The best way to prove medical necessity is through the provider’s documentation, which includes the initial intake, history, exams, daily treatment notes, a treatment plan with measurable functional goals, and imaging when appropriate. When medical necessity is established, this is called active treatment. When this criterion is not met, patient care is defined as maintenance, supportive or wellness care; thus, clinically appropriate, but not medically necessary. Most third-party payers only reimburse for active treatment. Your best defense against this error is to understand what the definition of medical necessity is for the third party. This is usually found within medical review policy or other documents like documentation requirements.
CPT and ICD coding doesn’t match documentation
Documentation and coding are inextricably connected. Coding must be derived from documentation and not the other way around. All too often, providers elect to use a code to describe a service or a condition and disregard whether the documentation supports the use of the code. This practice has caused audit failures as well as the black eye our profession has received when it comes to proper documentation.
One prominent example is when a provider treats the full spine, all five spinal regions, but the patient has one single complaint, in the neck. Adjusting all the compensatory areas of the spine relating to the neck pain may be clinically appropriate, but when complaints and findings are focused on the neck only, billing 98941 (3-4 spinal regions) or 98942 (5 spinal regions) is simply incorrect. Providers must prioritize the complaints and issues in the documentation and bill only for the medically necessary areas.
Make sure each complaint from the patient’s history is quantified in the examination. If there are findings in an area without complaint, confirm with the patient, and add to the consultative notes in the history to warrant treatment in that region. Ensure each area has a proper diagnosis and the patient’s treatment plan reflects all the treatment for each medically necessary area to be billed.
Documentation is missing
The rules say you may not submit a billing for any service not documented, or for which the provider has not properly signed the note. Unfortunately, it happens all too often. One provider reached out for help when they received an audit notice for three years’ worth of records, and they literally kept no patient records during that time. Unfortunately, while going through a divorce, their soon-to-be-ex-spouse knew this and turned the provider in as leverage in the divorce. There is literally no defense for charging and billing for an undocumented service.
Therefore, use the basics of best practice when thinking about documentation. Malpractice carriers urge you to document consent to treatment, where relevant, in writing. All patient entries should be recorded as soon as possible following (or during) a visit and dated to ensure chronological order. Contemporaneous documentation is defined by Medicare as within 24 hours. Put checks and balances in place to ensure all notes are complete and signed prior to billing submission.
Experimental, investigational and unproven procedures and techniques
Something like Graston or Active Release Technique (ART) is experimental? Who says? Unfortunately, the golden rule is defined as “he who has the gold, makes the rules,” and that may be your state board of examiners or the third-party payer you’re billing.
While certain techniques like NUCCA, and therapies like laser and dry needling, can do wonderful things for patients, they are often deemed medically unnecessary, as experimental, investigational or unproven. None of this means you can’t perform the service if it’s within your scope of practice. (See “clinically appropriate,” above.) But you must be aware of the documentation requirements for these techniques and services before simply adding them to your menu of patient offerings.
These types of services usually require advance notice to the patient and documented acknowledgement the patient is aware of the service’s status and willing to cover the cost of the service themselves. We find this information in one of the most important documents in your compliance arsenal: the medical review policy (MRP) for the service you’re providing from the payer you’re billing. Review the payer’s website for these policies and clinical guidelines for each service or technique you use in practice. Become aware of these limiting rules and document accordingly. Additionally, some boards, like the one in Colorado, require an additional notice of patient consent for these types of services.
Lack of provider’s signature and authentication
Who doesn’t sign their notes? This one may surprise you; however, we do see this often enough for it to be a concern. Typically, with electronic health record (EHR) software, signing the note means closing it out. A frequent error is the note is never closed out or finalized. Then, when records are requested, we haven’t reviewed it to make sure everything is finalized.
According to the Centers for Medicare and Medicaid Services (CMS), billing cannot be submitted for services when the provider’s note isn’t signed. Often, we find it may be as simple as a setting in the software. We urge you to make a practice of reviewing all records at the end of a shift or day to confirm any team member who participated in the care and writing of the note has indicated so, and the supervising provider has signed the note.
If you identify a medical record note or order that isn’t signed, all is not lost. An attestation may be submitted to confirm the authorship of the note. Also, if a note is signed late, it’s best practice to include an addendum as to why with the new signature and date. Generally, records should be signed within 24 hours of the service.
Documentation doesn’t have to be drudgery or a chore. It’s part of the patient’s expectation of care in your office, and one of the business responsibilities of licensed health care providers. Health record documentation is a component of compliance and a necessary part of practice. Strive to take these errors under advisement and make a commitment to continually improve your documentation practices. Improved compliance is usually followed by an improved bottom line.
KATHY WEIDNER, MCS-P, CPCO, CCPC, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P), a Certified Professional Compliance Officer (CPCO), and a Certified Chiropractic Professional Coder (CCPC). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. This year, celebrating 40 years of serving this profession, Weidner leads the largest team of certified specialists under one roof in the profession at KMC University, and is known as one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855–TEAM-KMC or info@KMCUniversity.com.