Radiology Coding Alert

Promote accountability to keep your staff consistent.

Cutting corners in your clinical documentation may appear to save your staff time, but sloppy record keeping can cause larger headaches down the road. These headaches could include poor medical outcomes for your patients or incorrect reimbursement for your radiology practice.

Radiology Coding Alert has compiled advice from experts as well as pointers from the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) to help you avoid the mistakes of improper medical record keeping.

Remember the 3 Cs for Proper Medical Record Keeping

In addition to current and future medical treatment, efficient medical record keeping expedites patient management. As NCQA says, “Consistent, current, and complete documentation in the medical record is an essential component of quality patient care.”

Examine these key elements and understand how they can help you build a foundation for better documentation.

Tip 1: Maintain Consistency

Institute a checklist of basic requirements and ensure that everyone making entries in the medical record knows and follows the list. Get started with the checklist for your practice by perusing the six core components of flawless medical record documentation, according to NCQA.

• 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.

See the full NCQA guidelines at www.ncqa.org/wp-content/ uploads/2018/07/20180110_Guidelines_Medical_Record_ Documentation.pdf.

Promote accountability: One way to make sure everyone complies with the checklist is to turn on the function in your electronic health record (EHR) that allows you to view the author of a note “by entry, not by the entire chart,” says Laurie Bouzarelos, MHA, CPC, founder and owner of Provider Solutions Consulting in Centennial, 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 radiologist, nurse, medical assistant, or scribe — is accountable and meets the standards for documentation.

Utilizing this functionality will help to ensure uniformity across all charts. Plus, it’s consistent with one of the NCQA guidelines suggesting that “all entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.”

Keep track of clinical course: In addition to the six NCQA core elements, “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. Take another step toward consistency by creating a template for documenting subsequent care and correspondence info.

Tip 2: Be Aware of Signoff Timeframes

A lack of timely signoff on the medical record is “a significant, common problem,” Bouzarelos adds. In her audits, she has found signoffs that range from zero 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. That leaves practices open to problems down the road, whether it be with the provision of quality medical care or problems with payment.

Medicare: This echoes the sentiments of CMS, whose guidance notes that “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)).

Although CMS guidelines do not set a specific time frame for signing off, 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, Wisconsin Physicians Service Insurance Corporation Government Health Administrators (WPS GHA), the MAC for Indiana, Iowa, Kansas, Michigan, Missouri, and Nebraska, “supports [the CMS] concept for all documentation and would offer a reasonable time frame of 24-48 hours,” according to Moore (www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/completion-of-documentation/).

State: You should also check out your state’s requirements and guidance for the timely authentication of medical record documentation, as some states provide those requirements.

Tip 3: Document the Details

The medical record must “tell the story” of the patient. Impress upon your providers the importance of being as scrupulous as possible, especially when documenting details that could affect decision making, such as allergies, past medical history, and pertinent medical conditions. In addition to helping with consistency, as mentioned in Tip 1, using a checklist also helps you ensure that the medical record is complete.

Case in point: Audit findings often show that there is no documentation of medication allergies, adverse reactions, or no known allergies (NKA) status, according to Bouzarelos. Using a checklist based on the NCQA core components would help to ensure allergy documentation.

Don’t forget: If the patient reports no allergies, you still need to make an allergy entry in the medical record indicating NKA. “Pertinent negatives are just as important as pertinent positives. Silence in the medical record should not necessarily be interpreted to mean negative or not applicable,” Moore maintains.