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Study OIG guidelines, expert advises
Here’s a tip for access managers looking to improve their department’s compliance IQ: Broaden your definition of documentation.
That’s advice from Michael T. Myers Jr., MD, MBA, director of health compliance strategies for PricewaterhouseCoopers in Boston, who emphasizes that "the bottom line is that documentation is more than the medical record."
Beyond the medical record and the CPT-4 code for "evaluation and management services," which is used to capture a lot of physician services, is "anything the physician or provider puts a pen to," Myers says. "There is a qualitative expectation of what good documentation is — that it is legible, fact-specific, chronologically ordered, with no obvious alterations. If there is any alteration, it generally should be initialed and dated."
OIG manual can help
Those kinds of qualitative documentation issues, Myers points out, are reviewed in the Office of the Inspector General’s OIG Program Guidance for Third-party Medical Billing Companies, a reference manual he recommends for anyone concerned with accurate billing.
"Quantitatively, when it comes to documentation, we’re talking about not only the medical record that needs to be logical and time-ordered, but also prescriptions, requisitions, advance beneficiary notices, any claims for billing, submission forms, and certification of medical necessity," he says. "Those are examples of other pieces of paper that OIG requires."
Most access managers, Myers suggests, are familiar with poor documentation, which is more often the rule than the exception. "Typically, what happens is that notes and orders and certification are illegible. What definitely should cause a red flag are if notes are scribbled, or intentionally altered, or there is missing information. You know the service was performed, but when you go through the record, you don’t find anything."
For example, a physician might care for a hospital patient over a period of time that includes a holiday or a weekend, Myers notes. "Billing may happen on the inpatient side, and [the biller] will assume the physician took daily care of the patient from admission to discharge. In fact, there were probably a few days where the physician did not directly provide service. That’s the most egregious example."
What access managers need to do, he advises, is understand that "there are definite expectations that have been voiced about what good documentation is" and then to meet those expectations.