Documentation tops list of compliance bugaboos

Here are key tips on what auditors look for

When the Office of the Inspector General (OIG) issued its model compliance guidance program for third-party billing companies in December, poor documentation headed up the list of suspicious and questionable billing activities. Poor documentation also is one of the top reasons claims get kicked back in prepayment audits, according to billing experts.

"Many physicians simply don’t see the reason for wasting time writing down all the details of a diagnosis they have already worked out in their head and which they feel is right and makes perfect sense," says Catherine Fischer, CPA, a reimbursement policy advisor at Marshfield (WI) Clinic.

Watch for these red flags

Indeed, Health Care Financing Administration auditors report that it is not unusual for them to find no documentation in a patient’s file to support what seemed to be an otherwise proper diagnosis and action taken by the doctor. That’s one of the key reasons claims get bounced back as "not medically necessary."

There are several red flags auditors automatically look for to determine if they should dig deeper into a provider’s files and past claims for suspicious activity, experts say. These include:

• Patient records that look alike.

The fraud police want to be able to compare the records of different patients and find slight variations in how they are documented. Even allowing for whatever documentation procedures a practice uses, auditors expect documentation methods not to be exactly alike between any two (or more) records.

"Using the same wording and checking off the same problem levels are the kind of things that catch an auditor’s attention," says OIG spokes man Ben St. John.

• Inconsistency between the chart and the evaluation and management guidelines.

When the information contained in a patient’s chart is not consistent with the related evaluation and management guidelines, this sends up another flare that gets the auditors’ attention.

• Mismatch between procedure code and setting.

Are you coding for procedures normally done in a hospital while claiming an office visit?

• Discrepancy between procedure codes and the diagnostic codes.

Does the prescribed treatment match the diagnosis?

• Spiked billing patterns.

Are your billings abnormally high compared to the average for a particular code or medical service, or compared to other physicians in your specialty?

• Incomplete or truncated diagnostic codes.

This is one of the most common reasons for issuing a medical necessity denial. If it seems like you have been receiving an unusually high percentage of rejections for certain procedures, make sure your codes and computer systems are up to date. Also, take a close look at your "5th digit" coding patterns to ensure they are both up-to-date and as specific as possible when it comes to completing the patient’s diagnostic profile.

The AMA’s Office of General Counsel has developed model physician compliance guidelines outlining the minimum standard each file should meet to properly document medical services that have been provided. Each patient encounter documented in the medical record should include:

• the reason for the encounter;
• relevant medical history;
• findings of the physical exam;
• prior diagnostic test results;
• current assessment, clinical diagnosis, or impression;
• care plan;
• date;
• name and identity of any observers;
• rationale for ordering any additional diagnostic or ancillary services and tests that are inferred but not documented in the record;
• past and present diagnoses made accessible to treating and/or consulting physician;
• identification of appropriate health factors;
• patient’s progress and response to treatment, any changes in treatment, and any revised diagnosis;
• CPT and ICD-9 codes reported along with appropriate documentation.