Primary Care Coding Alert

NCQA standards, experts shed light on common problem areas.

How important is accurate documentation? According to Julie Taitsman, Chief Medical Officer for the US Department of Health and Human Services, Office of the Inspector General, precise documentation benefits all participants in the world of medicine. "Proper documentation," says Taitsman, "is important to protect [Federal] programs, to protect your patients, and to protect your provider" (Source: https://oig.hhs.gov/newsroom/podcasts/2011/heat/heat09-trans.asp).

With so much at stake, it is also important that practices periodically review their documentation procedures and be as vigilant as possible with the information entered into their records. So, we've provided four specific suggestions, for you to begin, or to continue, your practice's program of compliance and improve the quality of your care.

NCQA Guidelines Provide a Great Starting Point

Laurie Bouzarelos, MHA, CPC-A, contracting and chart auditing specialist at Physician's Ally Inc. of Littleton, Colorado, suggests practices consider using the guidelines developed by the National Committee for Quality Assurance (NCQA). The guidelines feature 21 elements that, it believes, "reflect a set of commonly accepted standards for medical record documentation."

Specifically, the NCQA guidelines highlight six of the 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.

(For the full NCQA guidelines, go to http://www.ncqa.org/Portals/0/Programs/Accreditation/guidelines_medical_record_review.pdf?ver=2018-01-17-150157-490.)

Of all the elements in the NCQA guidelines, Bouzarelos identifies three in particular - and adds an additional element that shows up frequently in her audits - that practices should focus on in their attempts to improve the quality and accuracy of their documentation.

Make Sure Entries to the EHR Contain the Author's Identification

"In most audited charts," Bouzarelos notes, "there is no indication of who is entering the items in the medical record." Bouzarelos suggests turning this function on in your electronic health record (EHR) "by entry, not by the entire chart." This way, you can be sure the author of a note, whether it be a scribe, medical assistant, physician, or nurse, will be clearly indicated, an important detail in the team-based environment of primary care.

Make Sure Allergies are Documented in the EHR

"Often," Bouzarelos continues, "audit findings show there is no documentation of medication allergies, adverse reactions, or known allergies [NKA] status." Bouzarelos believes 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.

Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, agrees with Bouzarelos, emphasizing that "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."

This, Moore points out, "is consistent with the documentation guidelines for evaluation and management [E/M] services, which primary care physicians do most commonly; for instance, the documentation guidelines related to ROS and the exam refer to documenting pertinent/relevant negatives as well as positives."

Make Sure the Record Has Explicit Notation of Follow-up Plans

Here, Bouzarelos advises, "notes should include follow-up care, calls, or visits, if applicable. The specific time of return," Bouzarelos goes on, "should be noted in weeks, or months, or as needed."

Make Sure There Is a Timely Sign Off

Even though this is not on the NCQA list, Bouzarelos finds this to be "a significant, common area of problems" in her audits, which have shown a range from 0 to 58 days for sign off, 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.

Part of the problem here, according to Moore, is that CMS guidelines are not specific about a time frame for signing off. Section 30.6.1(A) of Chapter 12 of the Medicare Claims Processing Manual states, in part, "The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

However, Moore goes on to point out that "Medicare administrative contractors [MACs] have offered their own interpretation of what this means. For instance," Moore notes, "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 [24-48 hrs]'" (Source: https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/completion-of-documentation/!ut/p/z0/nZDNTsMwEIRfpRxytNZpUZVrQaCoSgTiUAVfkHEcd­6njdW2Hv6fHKdfSA8fZWc18uyCgA-HkOxqZkJy0WT-L9ctjXa_rsuLNw7LlfNPe71Z3VXNTPZWwBfH3wvWun­BOWob1tDQgv056hGwi6gcIYZw_fjkexAaHIJf2ZoPvw­cXESLi20MxbjvuCJPCqm8kyHgsupx1Tw34yLAD­PheQAzYa8jk65nQUeagtKZR9HorZ5vZzSwntQ05s7TM_4Lq6zEMRb8XGF2LxT6g3j9Wn03tTVXPzcpvjY!/#).

This is consistent with Bouzarelos' recommendation that practices complete documentation in their charts within 48 hours.