Medicare Compliance & Reimbursement

Question: How do I respectfully keep on top of a provider whose documentation about the timing of an encounter doesn’t always seem accurate?

Rhode Island Subscriber

Answer: Coders (and auditors) know that documentation is crucial to reporting an encounter, hence the maxim, “If it wasn’t documented, it didn’t happen.” But the inverse can make for some sticky situations: Just because an encounter was documented a certain way doesn’t mean it happened that way.

An easy but possibly inconvenient way to determine whether a provider is recording time appropriately for each visit is to try and get as close to the patient encounter as possible, so you (or whoever is responsible for provider education) can make sure the provider’s documentation matches the time actually spent and, if necessary, give feedback in real time. It’s a lot easier to determine compliance for matters like documentation — or gently correct behaviors that aren’t helpful — if you can have a conversation right away, instead of, say, scheduling a meeting and bringing in a report of the last 30 days’ charts.

If all of your providers seem to have trouble reporting time correctly or all struggle with some other issue, then that points to an organizational problem that may require systemic adjustment rather than individual provider education.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC