Are You in Documentation Denial?
DOCUMENTATION
Kathy Mills Chang
MANY OF THE DOCTORS WE MEET TELL US THEY’RE NOT TOO WORRIED ABOUT THEIR DOCUMENTATION. “WE’VE GOT THAT COVERED,” THEY SAY. “I THINK WE’RE PROBABLY FINE.”
We wish we shared their optimism, but statistics—as well as our own practical experience—tell us that their documentation is probably not anything close to fine. A few years back, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) reported that as many as 94% of chiropractic records are missing or inadequately presenting some key elements—evaluation, a treatment plan, medical necessity, and/or contraindications to treatment. That statistic matches up with what we generally find when we look at someone’s documentation as a sort of “white hat” auditor. Even DCs who tell us at the outset that they think their paperwork is solid will have documentation errors that put the practice at risk.
A recent new client is a great example. One of the blessedly open-minded, this DC came to us because of documentation concerns. She was horrified, though, when we found that her Medicare documentation error rate was 100%. 100%! That means that there was something seriously missing, miscoded, or misstated in every single Medicare claim filed by the practice. Their risk factor for an audit? Insanely high.
^Fortunately, as with most things, being willing to admit you may have a problem is a huge step in the right direction. JJ
These are the kinds of errors our “white hat” audits most commonly find:
1. Underand overcoding E/M services
The Centers for Medicare and Medicaid Services (CMS) has set forth clear guidelines for what is required for documentation and coding of these services. However, because many doctors have never seen these guidelines, they tend to use whatever code feels right, or rely on the amount of time spent. That means some doctors will end up “guessing” too high or too low for the amount of work performed. If you review your information and make a checklist of the items required, you likely will be surprised by how much work you’re doing that you’re not charging for, or you may find that you’re not documenting completely. Either way, both underand overcoding constitute waving a red flag. Auditors examine outliers—any doctor who falls outside normal billing patterns—more closely.
2. Coding and documenting incorrectly
Doctors know the treatment they give an individual patient, and therefore feel justified in how they code the service. If their documentation doesn’t support the code, though, it’s a problem. Remember, as far as a third-party payer (or auditor) is concerned, if it isn’t in writing, then it didn’t happen. So if, for example, you bill a chiropractic manipulative treatment (CMT) code for a certain level of service, but the documentation only justifies a lower number of regions treated, you’ve just waved another red flag. Note: these kinds of mistakes ai e most often found in postpayment audit reviews, and they can cost a practice thousands of dollars in repayment. This should be a reminder to ensure that your daily documentation record and billing record match exactly.
3. Cloning records or rote justification of medical necessity
When each chiropractic visit looks the same as the last and statements such as “same as last visit” pepper the daily notes, it’s difficult for a third-party reader to ascertain the necessity of each visit. Standard guidelines dictate what must be included, and it can be very easy to get into the trap of rushing through your daily documentation. Most documentation software programs allow you to start with the notes from the last visit, so you can modify from there. The error here is that when you get rushed or lax, you may be tempted to minimally modify and move on. Resist that impulse and make sure each visit and its documentation are “encounter specific.”
These aren’t the only mistakes we find, not by a long shot— others include easy-to-overlook mistakes, such as a doctor’s initials instead of a full signature or general illegibility in the notes. Any of them can kick back a claim. Any of them can be a problem in an audit.
Fortunately, as with most things, being willing to admit you may have a problem is a huge step in the right direction. Our client with the 100% error rate? Thanks to a lot of unflinching courage and a little hard work, that practice’s Medicare claim error rate is now 8%. Now, that’s a number that justifiably inspires confidence.
For those of you reading who are still thinking, “Yeah, that must have been one messed-up practice. Our documentation is fine,” well, you may be right. However, statistics show that you have a 94% chance of being wrong.
How do you like your odds?
Kathy Mills Chang is a certified medical compliance specialist (MCS-P). Since l983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 14 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 [email protected], www.KMCUniversity.com.
