Physicians know that clean clinical documentation is essential to get proper reimbursement. With increased pre- and post-payment audits and third-party scrutiny, you should make sure your practice isn’t missing a few crucial elements while documenting services.
Common Documentation Errors Identified in Audits
- Incomplete progress notes
- Unauthenticated medical records
- A lack of documentation showing the intent to order services or procedures
And CERT has identified three causes for high error rates in evaluation and management (E/M) services:
- Insufficient/incomplete documentation
- An incorrect application of the definition of medical necessity
- Inaccurate E/M codes
Incomplete documentation—due to misspelled words or incomplete sentences, blanks in documentation, and noncompliance with organizational policies—is often a major reason for lost revenue, and also compromises patient care and patient safety.
Common Pitfalls in Everyday Practice
When documenting diagnoses, keep in mind the following:
- Prepare for resistance. When educating physicians and staff, you must understand that there might be resistance to change—this could be because of a busy schedule, inadequate sleep, frustration with the electronic health record (EHR) and more as per AAPC.
- Avoid interruptions if possible. In busy medical practices, the potential of being interrupted is high, and a physician may end up recording incomplete information. Encourage clinicians to take extra time with their documentation, or even close office doors for a few extra minutes.
- Key in on EHRs. EHR systems often feature easy-to-use checkboxes, but these can also mean the wrong boxes can get accidently checked, thereby recording incorrect drugs or an incorrect diagnosis or symptoms.
- Acknowledge the challenge and ask for help. Acknowledging these challenges is the key to ensuring your documentation is accurate and complete. Some clinicians or even physicians may not understand coding, risk assessment, and hierarchical category conditions, and in such cases, expanding their clinical thinking can help with better documentation.
Best Practices for Correct Documentation
CMS expects that documentation is clear, concise, complete and legible, according to Irvine. Here are some best practices for good documentation:
- Include the reason for the encounter, the assessment, the diagnosis and clinical impression, a medical plan of care, the date and legible identity of the observer
- Ensure that the dates of procedures coincide and that each note is signed and legible, since the signature indicates the information is accurate and correct
- When documenting a particular service, provide the rationale for ordering diagnostic and ancillary services and include past diagnosis (history of) as well as present diagnosis
- Make sure the medical record also supports the diagnosis and treatments through adequate documentation
- In the medical record, provide details for the procedures performed, and include documentation specifying the correct dosage for any drugs prescribed
- Provide detailed information on LT, RT modifiers and other anatomical information
- New patients not identified in the medical record but billed as new patients should be documented as initial visit or new patient
In essence, good documentation should support and validate good communication, increase and recognize comorbid conditions, validate the care and treatment provided, and ensure compliance with quality guidelines. Even if you get paid for services, if your documentation practices are poor, you may not get to keep the reimbursement if an audit uncovers poor practices. The legal ramifications of incorrect documentation can also be huge: To protect against malpractice suits, you must ensure you have complete and accurate records of the services provided to patients.