Wiki Acceptable practice or fraud?

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kimberagame

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CORVALLIS, OR
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My clinic has been pushing me to query a provider when an office visit note would qualify for a higher E/M based on the MDM, but is missing the required documentation in the history and/or physical portion of the note. Our administrator feels that the providers aren't getting paid for the work they're doing and we need to help them get what they're entitled to. He believes they're legitimately leaving out details that would allow them to get that higher visit level, and we should be approaching them to enquire whether that's the case when we come across these visits. So, for instance, we should task and ask if they really only asked one ROS question, or were there maybe more that they just didn't add. Or can they provide any more details about the patient's pain that would get them to 4 HPI points? I've refused so far, as my understanding was this was not allowed. We can educate providers on what they need to have in their notes, but we can not go back after the fact and ask them if there's more they could add. It looks too much like we're having the provider add things that didn't really happen to the note to increase their level. But they're pushing again. I've tried to find documentation to support my argument, but had no luck. Does anyone know where I could look? Or am I wrong about this to start with? Our administrator is a former coder, and he feels quite strongly that this is fine. Thanks for any feedback!
 
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I strongly advise against this, as it seems you are trying to backtrack documentation to justify a higher level. To me, query is for unclear documentation, not to ask "don't you want to add another ROS to meet 10 for a comprehensive level."
I would suggest a reminder education for your providers and perhaps give a handful of examples. Over the years, I have found many instances of clinicians just simply not documenting well. But it needs to be a moving forward situation, not a change your previous documentation situation.
Healthcare fraud is an "intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, to the entity or to some other party." Requests for amendments or late entries to justify a higher level seem to meet that definition.
Here is a good article to use as a reference.
https://med.noridianmedicare.com/we.../documentation-guidelines-for-amended-records
 
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I agree, querying a physician to add documentation solely for the purpose of increasing reimbursement is considered a non-compliant practice. AHIMA publishes guidance on compliant query practices which most large organizations follow and incorporate into their policies. Here is one link where you can find some of this guidance, but there are many more if you perform a general search under 'compliant physician queries'.

 
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