Practice Management Alert

Rely on NCQA guidelines for concrete examples on what to do.

Maintaining accurate medical records is, in many ways, the backbone of medicine today because it provides a narrative of the patient’s condition and health history, as well as a means of demonstrating the ways in which a provider has earned reimbursement.

Context: “Consistent, current and complete documentation in the medical record is an essential component of quality patient care,” says the National Committee for Quality Assurance (NCQA), the organization responsible for the Healthcare Effectiveness Data and Information Set (HEDIS) performance improvement tool.

Look to these tips to boost your documentation skills and electronic health record (EHR) accuracy.

Use These Components as Your Foundation

A good first step is understanding the “commonly accepted standards for medical record documentation” according to the NCQA. The NCQA guidelines highlight six of 21 elements “as core components to medical record documentation.” They are:

• Significant illnesses and medical conditions are indicated on the problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
• Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
• Working diagnoses are consistent with findings.
• Treatment plans are consistent with diagnoses.
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

Resource: For the full NCQA guidelines, go to www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf.

Most would agree that all of these elements are central to good medical record-keeping. So, what are some of the ways you can ensure these elements are kept consistent, current, and complete?

Maintain Consistency

One way to do this is to turn on the function in your EHR that allows you to view the author of a note “by entry, not by the entire chart,” says Laurie Bouzarelos, MHA, CPC-A, contracting and chart auditing specialist at Physician’s Ally Inc. of Littleton, Colorado.

“In most audited charts, there is no indication of who is entering the items in the medical record,” Bouzarelos notes. By turning on this function and using it consistently, you can be sure the author of a note, whether it be a scribe, medical assistant, physician, or nurse, will be clear, an important detail in a team-based environment.

This is consistent with one of the other NCQA guidelines that suggests “All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.”

Consider a template for follow-ups: “Notes should also include information about follow-up care, calls, or visits, if applicable. The specific timeframe for all of these should be noted in weeks, or months, or as needed,” Bouzarelos suggests.

Stay Current

Even though this is not explicitly stated in the NCQA guidelines, a timely sign off on the record is “a significant, common problem” Bouzarelos has found in her audits, where signoffs have shown a range from 0 to 58 days, with one audit of 24 charts showing a nine-day average. “Plenty of things can be forgotten or misrepresented over this period of time,” Bouzarelos cautions, leaving practices wide open to problems down the road.

This echoes the sentiments of the Centers for Medicare & Medicaid Services (CMS), which notes “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record,” (Medicare Claims Processing Manual Chapter 12, Section 30.6.1(A)).

CMS guidelines are not specific about a timeframe for signing off, but local Medicare administrative contractors (MACs) “have offered their own interpretation of what this means,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “For instance, WPS GHA [the MAC for Indiana, Iowa, Kansas, Michigan, Missouri, and Nebraska] medical directors support this concept for all documentation and would offer a reasonable time frame of 24-48 hours.” See, for example, www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/completion-of-documentation. 

Additionally, you should also look to state guidance and requirements for the timely authentication of medical record documentation, as some states provide those requirements.

Be Comprehensive

“Often, audit findings show there is no documentation of medication allergies, adverse reactions, or known allergies [NKA] status,” Bouzarelos notes. But they should be noted prominently not simply because they are one of the NCQA core components, but because they could indicate an allergy to a specific medication.

Additionally, “pertinent negatives are just as important as pertinent positives, and silence in the medical record should not necessarily be interpreted to mean negative or not applicable,” Moore maintains.

In other words, the record should be as scrupulous as possible documenting the first three bullets of the NCQA’s core components to medical record documentation, which tell you to document all significant illnesses and medical conditions and include a thorough and easily found patient history that includes not just past conditions but pertinent conditions that are not present in the patient’s past, family, and social history.