Otolaryngology Coding Alert

Hint: Legibility and timing are still top concerns.

Coding accuracy might be your top priority when you think of preparing for an audit, but your physician’s documentation compliance is just as important. Start the New Year by helping your otolaryngologist focus on three key areas for improvement.

Area 1: Get Proper Authentication

Every medical record must have authentication. Every service your medical staff provides or orders should be authenticated by the author, according to 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 audioconference “Compliance: It’s Not Just About Coding.” All notes should be dated, preferably timed, and signed by the author.

Options: Authentication must be either a handwritten or an electronic signature. Remember 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.

A handwritten signature is considered a “mark or sign.” If the signature is illegible, Medicare shall consider evidence in a signature log. It is also recommended to include the providers’ initials on the 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.

Area 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,’” 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 “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.”

Area 3: Make Alterations Carefully

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 physician makes a correction, he should include the date and (preferably) the time of the amended note. Then, the person making the change should also legibly sign or initial the entry.

Example: Your physician accidently copies and pastes a sentence from one patient’s electronic record into another patient’s record. Someone in your practice later catches the error. “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, then it should not be taken out of the record,” Diamond says. “Correct it 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.”

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 and add the time to support the coding and billing.