General Surgery Coding Alert

Documentation:

Get Your Medical Records in Top Shape With These 3 Steps

Published on Thu May 19, 2022

Establish parameters for timeliness to capture detail.

Poor medical record hygiene may lead to poor medical outcomes and poor reimbursement for your surgery practice.

That’s why we have this refresher for you, based on our experts’ guidance, plus the words of Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).

3-Cs: As NCQA says, “Consistent, current and complete documentation in the medical record is an essential component of quality patient care.” Let’s go through these one at a time.

Step 1: Be Consistent

Establish a checklist of core requirements and ensure that everyone making entries in the medical record know and follow the list. Get started with the checklist for your practice by studying “Implement NCQA Documentation Guidelines for Optimum Medical Record” on page 6 for six elements that are core components in the medical record, according to NCQA.

Accountability: One way to make sure everyone complies with the checklist is to turn on the function in your EHR that allows you to view the author of a note “by entry, not by the entire chart,” says Laurie Bouzarelos, MHA, CPC-A, contracting and chart auditing specialist at Physician’s Ally Inc. of Littleton, Colorado.

“In most audited charts, there is no indication of who is entering the items in the medical record,” Bouzarelos notes. By turning on this function and using it consistently, you can be sure the author of a note, whether it be a scribe, medical assistant, physician, or nurse, is accountable and meeting the standards for documentation.

This is consistent with one of the NCQA guidelines suggesting that “all entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials.”

Don’t forget follow-up: In addition to the six NCQA core elements, “notes should also include information about follow-up care, calls, or visits, if applicable. The specific timeframe for all of these should be noted in weeks, or months, or as needed,” Bouzarelos suggests.

Step 2: Stay Current

Missing timely sign off on the medical record is “a significant, common problem,” Bouzarelos says. In her audits, she has found signoffs that show a range from 0 to 58 days, with one audit of 24 charts showing a nine-day average. “Plenty of things can be forgotten or misrepresented over this period of time,” Bouzarelos cautions. That leaves practices open to problems with quality medical care and problems with payment.

Medicare: CMS guidance notes “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record,” (Medicare Claims Processing Manual Chapter 12, Section 30.6.1(A)).

Although CMS guidelines do not set a specific timeframe for signing off, local Medicare administrative contractors (MACs) “have offered their own interpretation of what this means,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “For instance, WPS GHA medical directors support [the CMS] concept for all documentation and would offer a reasonable time frame of 24-48 hours” (See the web page “Complete and Timely Documentation of Medicare Services,” by WPS GHA, MAC for Indiana, Iowa, Kansas, Michigan, Missouri, and Nebraska).

State: You should also check out your state’s guidance and requirements for the timely authentication of medical record documentation, as some states provide those requirements.

Step 3: Be Complete

In addition to helping with consistency as mentioned in Tip 1, using a checklist also helps you ensure that the medical record is complete.

For instance: Audit findings often show that there is no documentation of medication allergies, adverse reactions, or known allergies [NKA] status, according to Bouzarelos. Using a checklist based on the NCQA core components should ensure allergy documentation.

Remember: If the patient reports no allergies, you still need to make an allergy entry in the medical record indicating NKA. “Pertinent negatives are just as important as pertinent positives. Silence in the medical record should not necessarily be interpreted to mean negative or not applicable,” Moore maintains.