These two things are simple, but have a powerful effect on success.
Documentation that gives your providers the best chance of optimal reimbursement has several key characteristics: reliability, precision, completeness, consistency, and clarity. As our experts share, taking even simple steps, such as double-checking signatures and verifying basic details about the patient, helps ensure that claims meet those criteria.
Get a Signature – Every Time
Payers won’t consider documentation to be valid — no matter how detailed it might be — if it does not include a signature or other authentication. “Regardless of who writes the medical record entry, the record must be authenticated by the provider,” says coder Ann Bina in Charlotte, N.C.
Here’s why: Medicare requires that services provided or ordered be authenticated by the author with either a handwritten or electronic signature. Stamped signatures are permitted in some situations, such as when the author has a physical disability that prevents them from signing the record.
Unsigned documentation or a lack of attestation will result in a claim denial, Bina says, which could cost your practice thousands in forfeited reimbursement.
Back-up plan: Provider signatures might not always be legible to the average reviewer (such as an auditor). To help prevent issues, your office can create and submit additional documentation to prove that the signature does belong to the provider in question. Practices often do this through submitting a signature log that lists the printed name of the author/provider, the provider’s credentials, and the provider’s initials and signature.
“A signature log is a typed listing of physicians and NPPs identifying their names with a corresponding handwritten signature,” CMS says in its document, “Complying with Medicare Signature Requirements.” It continues, “This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record. CMS encourages but does not require physicians and NPPs to list their credentials in the log.”
Conduct a Reality Check
Patients’ medical records follow them — forever. The use of technology-based record keeping makes it easier than ever for multiple clinicians to access information.
What it means: Providers should always double-check charts to ensure accuracy so that misinformation doesn’t become part of the record. While you might not know as a coder whether specific details are correct, you can read charts to verify that information doesn’t mistakenly carry over electronically from a previous visit’s note.
Documentation from within a practice will be similar, especially when software suggests signs and symptoms that frequently correlate with a diagnosis. That’s acceptable but copying and pasting from one chart to another is not.
“Payers are looking for cloned documentation,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, Cal. “That means they’re seeing the exact same thing for different patients for the exact type of medical record of what’s being submitted, and that’s where it becomes a problem.”
Another watchpoint: Verify that you’re choosing diagnosis codes based on the patient’s current circumstances rather than their history. If more than one diagnosis code applies, include all on your claim instead of singling out one. Also include the reason for surgery on your claim, says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl.
Bottom line: Every detail in a patient’s chart can either help or hurt your provider’s potential reimbursement. Double-checking signatures and patient histories might seem elementary, but your providers will thank you when their bottom line reaps the benefits through higher reimbursement and smoother claims submissions.
