Ensure Documentation Supports Reimbursement

By Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS
As a physician auditor, I spend much of my time educating clinicians on proper documentation. This involves explaining and interpreting coding and compliance guidelines. When providing such guidance, the most common reply I hear from providers is, “I want it in writing.” An auditing compliance plan helps to satisfy this need.
Formulate a Plan
An auditing compliance plan gives providers written details of what is expected and/or permitted for documentation and billing purposes. For example, a plan may specify what terminology is permissible, which examination guidelines will be used, and the documentation required to support a type or level of service.
An effective plan also provides a map for all auditors (internal or external) to follow, and shows a practice’s “due diligence” in monitoring, education, and documentation. Finally, per the Office of Inspector General (OIG), auditing and monitoring of physician documentation is required.
Get It in Writing
The accompanying sample auditing compliance plan (pages 48-51) can aid in developing an effective plan of your own. Use this as a guide only; your auditing compliance plan should be based on your medical practice, Medicare/payer guidelines, and the recommendations of your compliance officer. I also recommended your practice’s health care attorney to review any compliance plan you put in place.
Put Your Plan into Motion
Formulating your auditing compliance plan is step one. You must also put the compliance plan into effect and ensure that it’s followed.
Auditing Compliance Plan Sample
A. Purpose of Audits
(Name of Medical Practice) promotes adherence to an Auditing Compliance Program as a major element in the performance evaluation of all Providers/Non-physician Practitioners (NPPs) documentation. Providers are bound to comply, in all official acts and duties, with all applicable laws, rules, regulations, standards of conduct, including, but not limited to laws, rules, regulations, and directives of the federal government and the state of ______________, Medicare Contractor, Fiscal Intermediary (FI), or Carrier (Name of MAC Provider) and rules policies and procedures of (Name of Medical Practice).
B. Orientation and Training
All new Physicians/NPPs will receive orientation and training in documentation and auditing policies and procedures. Failure to participate in required training may result in disciplinary actions, up to and including, termination of employment. Every Physician/NPP is asked to sign a statement certifying they have received, read, and understood the contents of the auditing compliance plan.
C. Education
Every Physician/NPP will receive periodic training updates in auditing. Ongoing education will be based on regulatory changes. Attendance is mandatory for all providers.
D. Audits/Monitoring
Auditors will conduct ongoing evaluations of compliance auditing processes involving thorough monitoring. The audits will inquire into compliance with specific rules, policies, documentation and policies of Medicare FIs or Carriers. Audits should identify any patterns and trends, non-compliance, or violations.
All audits will be performed by Certified Coders with one or more of the following credentials; (CPC®, CPMA®, etc.). Auditors will be audited by external resources to monitor their accuracy and performance.
Frequency of Audits 
Internal audits will consist of a minimum of 10 audits per Provider and will be conducted on a (monthly/quarterly/semi-annual/annual) basis. They will be selected on (random basis, trending reports, frequency).
Audit Error Rate 
Error rates will be conducted with Provider audits and required to pass audits at a minimum of (90 percent is recommended).
Auditing Reports
Following each audit, Physicians will receive a written report, including:

  • Patient name/date of service
  • Provider name
  • Level billed/level documentation supports
  • Diagnosis codes billed/diagnosis documentation supports
  • Any coding/billing discrepancies
  • Medical necessity
  • Recommendations/concerns
  • Auditor name

E. Non-compliant Physicians/NPPs/Auditors
When disciplinary action is warranted, it should be prompt and imposed according to written standards of disciplinary action. Continuous violations will be reported and the Medical Director will determine the appropriate actions.
F. Documentation Requirements 
New vs. Established Patients
Documentation should clearly state when the patient is new to the practice. A new patient is one that has not been seen within the same group practice in three years.
Component Requirements
These three components will be used to qualify the level of service performed. If any of the components is missing from the documentation, the services will not be billed.

  • History
  • Examination
  • Medical decision making

Counseling/Coordination of Care/Time

  • Documentation requirements:
  • Time spent counseling, detailed documentation of counseling
  • Coordination of care – documentation of time, detailed documentation of coordination of care provided, and conversations with other health care providers

Chief Complaint
The medical record should clearly reflect the chief complaint. The chief complaint will support the medical necessity of the services/procedures provided.
Three chronic illnesses can be used for an extended history of present illness (HPI).
HPI can be recorded by the ancillary staff or by the patient, but must be reviewed and confirmed by the provider.
Review of systems (ROS) and past medical, family, social history does not need to be re-recorded if obtained during an earlier encounter; however, documentation of no change, and that the information was reviewed, must be noted.
Documentation should clearly reflect the patient condition or circumstances that prevented the provider from obtaining any history.
Documentation of unremarkable and non-contributory are not acceptable forms of documentation.
Documentation of normal or negative is permissible, but abnormal findings must be described.
ROS must meet medical necessity of the systems reviewed.
“All others negative” (is or is not) acceptable with (your FI name).
If an element is used in the HPI, it cannot be used in the ROS.
All audits are based on 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.
The extent of examination performed must meet medical necessity for the patient’s illness, condition, or injury.
Abnormal or any relevant negative findings should be documented and described. Negative, normal, unremarkable, and/or noncontributory are not acceptable forms of documentation.
Certain acronyms are not permissible. Each organ system or body area should be described in detail.
1995 Exam
The level of examination for 1995 guidelines will be determined as:

  • 1 body area or 1 body system – Problem Focused
  • 2-4 body areas and/or body systems – Expanded Problem Focused
  • 5-7 body areas and/or body systems – Detailed
  • 8 or more body systems – Comprehensive

Medical Decision Making (MDM)
No credit is given for a diagnosis that is not applicable to that day’s visit, unless it is a secondary issue.
Diagnoses must have relevance to the treatments provided or ordered.
Attending Physician should document when interpretation was done, and the results.
If history is obtained from someone other than the patient, this information must be documented.
When old records are reviewed, document that fact, along with a summary of those records.
Discussions with other health care providers must be documented, with a summary of the conversation.
Diagnosis Codes 
Diagnosis codes for billing services, and ordering ancillary services, must be supported in the medical record.
Include information that will be important for ICD-10. 
G. Other Evaluation and Management (E/M) Coding Guidelines
Critical Care (99291-99292)
Critical care must be supported by documentation. Time spent with the patient in critical care must be documented in the medical record. If the patient is unable to participate in discussions, time spent with family members or another decision maker must be documented.
Consultation Visits (non-Medicare Patients)

Consultations must be documented as a request for an opinion from another provider. It is the Provider’s responsibility to make sure a report is written to the referring Provider. The report must be documented. The documentation must state the reason for the consultation, as well as the Provider’s opinion and recommendation.
Observation Care Codes (8-hour Rules)
(99218–99226, 99234–99236)

Observation services that are less than 8 hours and performed on the same calendar day: Report 99218-99220 without discharge code 99217.
Observation care performed at a minimum of 8 hours, but less than 24 hours, on same calendar day: Report 99234-99236 without 99217.
Patients admitted to inpatient for less than 8 hours: Report 99221-99223 without discharge codes 99238-99239.
Prolonged Services (99354–99357)
Codes 99254-99357 must be used with other E/M codes.
Time spent with the patient must be face-to-face and documented in the medical record.
Each additional 30 minutes (minimum of 15 minutes) must be documented.
Documentation must support billed prolonged services.
Prolonged services without face-to-face services (99358-99359) are not billable.
Care Plan Oversight
Care plan oversight can be billed for patients in office/outpatient, hospital, home, nursing facility, hospice, home health agency, or domiciliary settings for non-face-to-face services.
Only one Physician can report care plan oversight per month.
Documentation must detail:
i. Patient name, date of service
ii. Detail of services performed
iii. Time spent on non-face-to-face services
iv. Physician name
Preventive Medicine (99381-99397)
Office E/M (can or cannot) be charged during a preventive visit for any abnormality that is encountered.
A separate note for the abnormality must be documented to support the visit.
Any insignificant problem or abnormality is included in preventive care.
H. Procedure/Surgery Documentation
Procedures performed without an E/M component must be documented in detail with:
Date of surgery, patient name and date of birth, surgeons, anesthesiologist and type of anesthesia used, facility where services were performed, consents obtained, preoperative diagnosis/postoperative diagnosis, indications for the procedure, IV infusions, description and details of procedure, findings, complications and how they were resolved, diagnostic reports/pathology reports, intra-operative information, postoperative condition of patient, and signatures.
I. Cloning Documentation
Cloning is “cut-and-paste” documentation resulting in the medical record being worded exactly the same or similarly to previous entries or encounters. Cloning is not acceptable.
J. Medical Necessity
Auditors will take reasonable measures to ensure that claims for services for office encounters and all procedures performed are reasonable and necessary, given the patient’s condition. All documentation must meet the medical necessity and MDM of the level charged.
K. Addendums/Late Entries 
Any corrections to the medical record, such as addendums or late entries, are acceptable within (days/weeks/months). Dates of addendums/late entries must be documented.
L. Acronyms
Below are the only acceptable acronyms used for (Name of Medical Practice):
(e.g., Acceptable: 
1. HTN – Hypertension
2. COPD – Chronic Obstructive Pulmonary Disease
1. HEENT in examination)
M. Handwritten Notes
Handwritten notes (i.e., hospital encounters that are handwritten) will be reviewed by two separate auditors, if illegible. If either auditor is unable to decipher handwritten information, the documentation will be considered non-billable.
N. Modifiers
Modifier use will be audited according to frequency and proper use.
O. Advanced Beneficiary Notice
f Noncoverage (ABN)
ABNs must be presented to the patient before a service/procedure is performed to notify the patient that Medicare may not cover the service. The entire form must be completed and signed by patients, but only for those services that may not be paid by Medicare.
P. Unbundling of Services 
Some services are bundled into services per National Correct Coding Initiative (NCCI) edits. These services will not be unbundled per the request of a Provider unless documentation or modifiers support the medical necessity. Some items—such as pulse oximetry and electrocardiograms—are routinely bundled into office visits and not billed separately.
Q. Global Days/Surgical Packages 
Services included in global days and surgical packages cannot bill be separately.
R. Incident-to
NPP professional services can be billed as incident-to with the following guidelines.
New patients are not billed as incident-to.
Established patients with new problems are not billed as incident-to.
The Supervising Physicians must be present in the office and immediately available when billing incident-to.
S. Scribes
The record must be clear that the Physician has performed all components of the service. Documentation should include that the information was obtained by the scribe acting on behalf of the Physician, the scribe’s name, and the date. Documentation should include a statement that the information obtained by the scribe has been reviewed and verified by the Physician.
T. Signatures
All signatures should be original or electronic and legible. Stamped signatures are not allowed. Attestation statements may be required if signature requirements are not met.
U. Teaching Physician Guidelines
Provided office services will be determined by the combine documentation from the Resident and Teaching Physician. The Resident can document his or her services in the office and the Teaching Physician must also document his or her participation of the service rendered. If documentation is incomplete or invalid, the Teaching Physician must document as if services were performed in a non-teaching setting.
Most practices have a medical director or a physician who is a “cheerleader” and supports coders, auditors, and compliance standards. This is the person you want to have help you develop and implement your plan. If you have a physician’s support, you have won half the battle. Organize an auditing compliance committee to develop the plan, and meet regularly for follow-up, amendments, and disciplinary measures with non-compliant individuals. You cannot expect your physicians to follow all rules and regulations without proper training.
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, is owner of Career Coders, LLC, a medical billing and coding school in Colorado. She served as an officer on the AAPC National Advisory Board.

Certified Professional Medical Auditor

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No Responses to “Ensure Documentation Supports Reimbursement”

  1. Leonarda says:

    Hello~ I am looking for guidance. I am a coder for a small CAH hospital. I have a few physicians who will document on an outpatient test requisition all of the patients current condition and then some. Example one physician ordered a UA. His diagnosis was chronic cystitis along with RLS, vitamin D deficient
    hypertension, hyperlipidemia along with the Z0000 and other diagnosis. I have spoken to his about this but it continues. Where can I find it in writing that they should not be doing this?