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 a payer or government scrutiny at any time.

1. Start with Authentication Requirements

Every medical record must have authentication. Every service your medical staff provides or orders should be authenticated by the author. All notes should be dated, preferably timed, and signed by the author.

Authentication must have either a handwritten or an electronic signature. Note that signature stamps are not acceptable for Medicare and many other payers. Initials are acceptable as long as they clearly identify the author, such as the initials are written over the provider’s printed name or a signature log exists and is provided to support the initials to a specific provider. See Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4.

Handwritten signatures are 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.

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

When your providers actually complete their documentation matters. Documentation should be generated at the time of service or, as Medicare puts it, “shortly thereafter.”

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 “shortly thereafter,” experts say. 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 corrected 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 as a late entry. 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 that comment is totally inappropriate for that particular patient, then 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.”