Medicare Compliance & Reimbursement

Auditing your staff documentation techniques will keep your payments on the up-and-up.

As the CERT results from 2016 highlight, practices can be their own worst enemies. Shorted out of millions, the report revealed that the primary culprit for most practice claims debacles were usually related to improper documentation. Whether it was a misunderstanding between physician and coder or a lack of sufficient information and necessity, Medicare providers in every state suffered major financial losses.

Notes and codes. If the charting is messy and vague, then coders are left to decipher illegible documentationwith the tough job of translating these notes into Medicare claims. “Documentation is an essential factor in the success or failure of the coding process,” says Nikki N. Taylor, MBA, COC, CPC, CPMA, an auditor with TCI Consulting & Revenue Cycle Solutions, “Provider documentation must provide a clear and complete picture of what occurred during the visit which will allow the coder to properly code the case.”

It’s All in the Details

Being on the same page helps to keep documentation errors to a minimum, which essentially improves your revenue and reward. Unfortunately, in settings both big and small mistakes do happen, but ensuring that your notes are metaphorically bulletproof helps to eradicate the types of common errors found in the CERT report. 

Avoid the time crunch. Under some healthcare regimes the pace can be extremely fast, and coders feel obliged to make shortcuts to meet the time constraints. This is when omissions and abbreviations from both provider and coder can lead to audits and Medicare payment reversals.

“From experience, providers will often omit key information from the medical record documentation and assume that the person reading the documentation does not need a detailed account of the visit,” Taylor says. Oftentimes, coders will enquire about the mixed messages, but sometimes they don’t, and that can lead to trouble.

Here’s why an internal audit helps: Healthcare has become extremely complicated over the past 20 years, and in order to stay fiscally sound and remain in compliance with the necessary standards, practices and hospitals must check themselves regularly. Both internal and external audits done annually allow you and your staff to see where you need improvement. Your results might show that your practice continually makes coding errors by using the wrong modifiers or drops the ball when it comes to enforcing HIPAA. 

Taylor recommends that providers take advantage of auditing as a tool to overcome “poor coding habits and poor documentation.” She says that regular auditing helps with the following: 

• Rectifies coding controversies.
• Measures the quality of your patient care. 
• Reforms staff compliance issues.
• Promotes the need for education of both providers and coders.
• “Assists with charge capture.”
• Provides you with the data necessary to combat “government scrutiny.”

Tip: Take a look at your EHR or engage a certified health IT vendor about documentation auditing. Many EHRs contain tools for performing an electronic documentation audit, which will give you a heads up on what your practice needs to work on to meet CMS standards.