Practice Management Alert

Hint: Documentation is always a boon to fewer denials.

Complete, accurate documentation can be the difference between a clean claim and a denial.

Here’s why: Payers and auditors look for supporting details that prove medical necessity and appropriate evaluation and management (E/M) levels. But patient medical records are not only critical to fair reimbursement; they also contain the information that will help determine future care. Sometimes, your job as a coder is to identify whether these notes are complete and seek out additional information as needed. However, that’s not as easy as it sounds.

Check out this helpful guidance for reviewing a patient record and some tips for effective and respectful provider queries.

Use CMS Guidelines for Proper Documentation

The Centers for Medicare & Medicaid Services (CMS) stresses that, for a claim to be valid, there must be sufficient documentation to verify services performed were “reasonable and necessary,” and “supports the level of service” billed. In other words, if documentation is missing or insufficient, then there is no proof the reported codes accurately represent the encounter. Furthermore, if the documentation does not support paid claims, reimbursement may be considered an overpayment, and CMS could end up recouping the funds.

CMS dictates medical record notes should meet the following criteria:

1. Notes are complete and legible.

2. Notes include:

• Reason for the encounter, relevant history, findings, diagnostic test results and date of service;
• Assessment, clinical impression or diagnosis;
• Plan of care; and
• Date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses are accessible to the treating and/ or consulting physician.

5. Appropriate health risk factors are identified.

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis are documented.

7. The treatment and diagnosis codes (as well as the level of care) reported are supported by the documentation.

(Source: www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/Downloads/ eval-mgmt-serv-guide-ICN006764.pdf).

Rely on E/M Notes

While CPT^® makes it clear that its E/M guidelines don’t establish documentation requirements or standards of care, it does remind coders of the main purpose of documentation. Proper documentation is meant to “support the care of the patient by current and future health care team(s),” according to the E/M Guidelines.

H&P is still important: It’s a common misconception that since history and physical exam haven’t directly contributed to office/outpatient E/M code selection since 2020, there is no reason to spend time documenting the history and examination. But exams and history are very much still part of the E/M services, and therefore, must be documented. E/M guidelines and codes that have levels of service tell you the service must include a “medically appropriate history and/or physical examination, when performed.” Remember, the purpose of a complete medical record is to provide thorough information for current and future healthcare teams.

Analyze the Medical Record for Specificity, Too

The quality of the provider’s documentation allows coders to not only code with accuracy, but also to the highest specificity.

It’s important the provider get credit for all the work done. “When I’m analyzing a record, I like to use the acronym M.E.A.T., which stands for Monitor/Manage, Evaluate, Assess/ Address, and Treat,” explains Keisha Wilson, CCS, CPC, SPMA, CRC, CPB, AAPC Approved Instructor at KW Advanced Consulting LLC in Brooklyn, New York. The acronym allows you to look at the patient record and see if all those elements have been addressed in the documentation by asking questions such as the following:

• Are there symptoms that show the progression or regression of a disease? (Monitor/Manage)
• What are the providers doing to evaluate this condition, and what are the tests ordered? (Evaluate)
• What tests have the patient had in the past/today? What were the findings? (Evaluate)
• How are the providers assessing and addressing the condition today? (Assess/Address)
• What is the plan for treatment? (Treat)

“If a provider keeps the term M.E.A.T. in mind, they will often have all the needed information for the coder to code the encounter without many queries,” Wilson says.

Query a Provider in Situations Like This

Whenever there is inconsistent, missing, unclear or illegible documentation, query the provider immediately. To avoid unnecessary queries or incomplete queries that create more questions, read over the record carefully and look for gaps in the documentation relating to the following: