Part B Insider (Multispecialty) Coding Alert

Make sure doctors date all new entries on patient records

If you suspect that someone in your practice has been rewriting history, you need to get to the bottom of it immediately.

When someone improperly revises patient documentation, it can create huge compliance problems as well as jeopardize payments, say attorneys.

Attorney Gary Eiland with Vinson & Elkins in Dallas has seen two situations where improper revisions have caused problems for a physician practice:

1. An administrator at a practice required doctors to route all charge slips through his office before they went to the billing department. Eventually the practice discovered that the administrator was upcoding the CPT Codes on the charge slip by raising each evaluation and management visit by one or two levels. Then when the payments came in from Medicare, he was skimming and embezzling the difference between the E/M level the physician had marked down and the higher level the carrier had paid.

The practice found out and called in Vinson & Elkins, then performed a self-disclosure to state and federal officials. The practice was able to point to the bad guy, Eiland recalls. The administrator served some jail time after a plea bargain. Lucky for investigators, the administrator had kept two sets of books - one with the E/M levels as the physicians had coded them, and one with the levels as he'd revised them.

2. A physician was put on post-payment review and asked for medical records for an identified sample of patients. The physician decided to come in on the weekend and supplemented his notes for those patients. He wasn't trying to falsify the records, merely to flesh out his recollections, because "you only have so much time to complete the chart," says Eiland.

This would have been fine if the doctor had remembered to date the new notes so it would be clear that he'd added them later. Instead, he left the new notes undated. He didn't realize that the carrier staff had already examined some of those patient records, and thus recognized immediately that he'd added information. Instead of merely repaying those claims, the physician ended up paying civil monetary penalties, Eiland reports. "I told him he was extremely lucky that he didn't end up facing criminal charges."

"There's nothing wrong with jotting down today your recollection" of a visit that happened a few months ago, Eiland notes. But you must write down today's date next to that note. "Don't give the appearance it was contemporaneous with the actual date of service if it wasn't," he cautions.