Wiki Auditing/documenting HPI to correspond with diagnosis code

[cubbiecatz]

I have been requested by a physician to show her in writing where her notes (HPI) must reflect the specific diagnosis she is choosing and why the diagnosis code isn't enough. The issue in debate is her picking mixed hyperlipidemia, but in the HPI she is stating patient has hyperlipidemia, nothing else other than maybe it's stable, but nothing to support how mixed or pure, was known to be the specific diagnosis.
My understanding has always been the notes have to support the final diagnosis and the doctors opinion is that I am wrong so she wants to see it in black and white. Nothing I have said or explained made a difference. The doctors also believe we will never get hit with an audit so they don't understand why it's so important to follow the rules and requirements.

Can anyone help?

Thank you, Cathy Satkus, CPC

 

[Pam Warren]

There's a lot of information in the 1995 and 1997 guidelines about appropriate documentation and the rationale. Basically, the codes reported on the claim have to be supported by information in the note. The HPI, Exam, MDM should all show the consecutive steps to the provider's logical conclusion of the diagnosis. Otherwise, without reference of the problem in any of the key components, the level of service wouldn't be supported, or medical necessity won't be met. Additionally, diagnosis codes are more specific in the ICD-10 environment, and this is going to impact their bottom line. Have her read about Medicare Advantage Plans, and the concept of HCCs. I always ask my more reluctant providers to document as if they were going to have to support their note during litigation. It's a bit of overkill, but it's often what gets them to recognize the importance.

Hope this helps.

 

[cubbiecatz]

That does help, thank you Pam. I try to say the same thing about litigation or audits but the last response was we will never be audited. I will show her those along with the CMS ICD-10 guidelines about specificity.
I appreciate your help!

 

[Cheezum51]

In regards to audits, I have heard from several of my colleagues recently that they are receiving requests from several different carriers, in addition to Medicare, for copies of patient records for audits. Some are being asked for as many as 60 patient records.

This is somewhat unusual because, historically, most might receive a request for 10 records for a routine check every few years. Now the requests are coming more often, for more records and some providers have noted that many of the records requested are for patients who may have a diagnosis or specialized testing in common.

There is just too much money being paid improperly or over paid by insurers for them to not increase audits.

Tom Cheezum, O.D., CPC, COPC

 

[Pam Warren]

Maybe CMS won't audit, but as part of your organization's compliance plan, (per the OIG's recommendation) you should be performing audits, or having a third party audit firm do them for you.