Oncology & Hematology Coding Alert

Do not assume EMRs are flawless.

Documentation compliance is as important as coding accuracy when it comes to facing an audit by the payer. Complete and clear documentation can go a long way to save you from potential denials or fines. You can adopt some simple rules to ensure your provider documentation can face payer or government scrutiny at any time.  

1. Start with Authentication Requirements

Every medical record must have authentication. Every service your medical staff administers or orders MUST be authenticated by the author, says Marsha S. Diamond, CPC, CPC-H, CCS, coding textbook author and past AAPC National Advisory Board member and past Greater Orlando (FL) AAPC Chapter President in the Audioeducator.com audio conference "Compliance: It's Not Just About Coding." All notes should be dated, preferably timed, and signed by the author.

Authentication must be either a handwritten or an electronic signature. Note that signature stamps are not acceptable for Medicare and many other payers. In the office setting, initials are acceptable as long as they clearly identify the author.

Handwritten signature will be considered a "mark or sign." If the signature is illegible, Medicare shall consider evidence in a signature log. Lack of such supporting documentation will result in claims denial. "Very simply, UNSIGNED ORDERS ARE NOT VALID to support the claim and resulting reimbursement!" says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner of Pinnacle Enterprise Risk Consulting Services, LLC.

Remember: Every note must stand alone, meaning that the performed services must be documented at the onset. The medical record must stand on its own with the original entry corroborating that the service was rendered and medically necessary.

Ensure legibility: Every entry in a patient's medical record must be legible to another reader to a degree that a meaningful review may be conducted. If the signature is not legible and does not identify the author, a printed version should also be recorded.

2. Check Timing Requirements

The time your provider completes their documentation is important. "Documentation should be generated at the time of service or, as Medicare puts it, 'or shortly thereafter,'" Diamond explains.

Delayed entries within a "reasonable" period of time are acceptable for the purposes of:

• Clarification
• Error correction
• Addition of information initially not available
• Unusual circumstances prevented generation of note at time of service (for example, if your EMR system is not working).

Rule of thumb: Payers don't typically give a set timeframe on what qualifies as "or shortly thereafter." Diamond explains that the rule is usually that you are in good shape "as long as the documentation is in the chart and documented in the time that the author has 'total recall' of the patient encounter or service."

3. Be Careful Making Alterations

The medical record cannot and should not be altered. Errors must be legibly with an obvious notation of the reason for correction so that the reviewer can draw an inference to its origin. If your provider makes a correction, he should include the date and (preferably) the time of the amendment. Then, the person making the change should also legibly sign or initial the entry.

Example:  Your provider accidently copies and pastes a sentence from one patient's record into another patient's record. Someone in your practice catches the error later on. "Even if you realize that you put it on the wrong patient's record or that the comment is totally inappropriate for that particular patient, it should not be taken out of the record but corrected using an appropriate method such as lining through it and initialing above it and the date [added and a statement] to say that was an error," Diamond says.

Be clear: Delayed written additions/explanations serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For example, if your practice did an audit and found that one of your providers was billing based on time but never included the total time spent with the patient in the chart notes, you cannot go back later and add the time to support the billing.

4. Know the Rules for Using Scribes

If a "scribe" is documenting for the provider, the individual writing the note or entry in the medical record should note "written by (name of NPP), acting as a scribe for Dr. (Physician Name)."

The physician should then co-sign and date the record, and also indicate that the note accurately reflects work and decisions he made during the encounter.

5. Watch Out for EMR Pitfalls

With the introduction of electronic medical records (EMRs) the capability of "carry over," repetitive "fill ins," and note cloning has become prevalent, Diamond says.

Remind your providers - and coding/billing staff - that only medically necessary information is considered when you are deciding on the code to bill based on supporting documentation.

Copy/paste, cloning, and the act of carrying information forward from another record or another portion of the record have the same effect on the integrity of the medical record. "It is almost unavoidable. Eventually an error will be made causing contradictions of fact to occur in a patient's record. Errors of fact are a bigger risk to the provider in and of itself," Loya says.

Example: First Coast Service Options, the MAC in Florida, prohibited the practice of cloning in its 2006 Medicare Part B newsletter: http://medicare.fcso.com/Publications_A/2006/138374.pdf, which states "Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment."

First Coast further states that discovery of this type of documentation will "result in denial of services for lack of medical necessity and recoupment of all overpayments made."

Bottom line: Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Credibility of the record is compromised, and an auditor will be unable to determine what is accurate and how much work was done in one visit versus how it compares to others.