Medicare Compliance & Reimbursement

Implement these 7 claims review checks to avoid denials.

There's nothing more frustrating than losing money you've earned. And that's exactly what happens when your claims are sent back due to insufficient documentation.

Complete documentation is a requisite for clean claims. "To put it in simple terms, if documentation does not support the procedures or diagnosis, you do not get payment," cautions Dianne Nakvosas, ACS-RAD, a senior medical coder at Compubill, Inc., in Tinley Park, Illinois.

Consider the following seven tips for quality clinical documentation, and evaluate how your practice claims, as well as coding and billing compliance protocols, stack up.

1. Legibility: Documentation should be readable and easily deciphered. A lot of handwritten documentation isn't legible or decipherable. Rushed or careless documentation may cause other problems. Legibility includes being able to read the name and title of the clinician completing the documentation.

Legibility is an especially important aspect of good documentation. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient's condition.
• Jeopardized reimbursement.
• Denied payment.
• Loss of legal appeals.
• Serious patient injury.

Although the use of electronic health records has vastly improved documentation legibility, many practices are still manually writing some notes, orders, and prescriptions by hand, so this is an area that should always be reviewed for clarity.

2. Reliability: Is the documentation trustworthy? Based on the diagnoses, is the documentation reliable? Does it support the rationale for the diagnoses and for medical necessity?

The reliability is not just related to the assessment, but with every single visit note. Most denials and downcoding instances occur when visit notes don't support the codes you report.

3. Precision: Clinical documentation must be accurate, exact, and strictly defined. Increased detail generally means greater accuracy in documentation. The degree of specificity in documentation that was made necessary with ICD-10 has been known to challenge even the most experienced clinicians. The same can be said for selecting E/M levels - without extremely thorough notes, E/M claims are often found to be upcoded because the doctor didn't record enough information to support higher codes.

4. Completeness: Good documentation fully addresses all concerns in the record, and includes appropriate validation.

5. Consistency: Documentation shouldn't be contradictory. Are there conflicting statements in the record? Are there conflicting opinions between providers that have not been clarified? Make sure any inconsistencies are addressed.

This is where smooth coordination of services comes into play. Many times, a contradiction occurs when there is a lack of communication between the disciplines, so everyone should be on the same page.

6. Clarity: Documentation should be unambiguous. Vague documentation that does not totally describe a patient's condition won't support the services your practice provides.

7. Timeliness: Documentation must be up to date to help ensure optimal patient treatment. Any delay in documenting can cause the clinician to forget important details that are critical to code selection.