Anesthesia Coding Alert

Help preserve medical record accuracy by promoting timely chart sign-off.

It’s a good idea to periodically review your providers’ documentation practices, as they can have far-reaching impacts. Spot-on documentation is a crucial part of a practice earning money — as well as conveying an accurate portrayal of a patient’s condition and medical history.

Avert the disastrous consequences of poor medical record hygiene, such as poor medical outcomes or losing out on hard-earned reimbursement, by heeding the advice of our experts and taking some pointers from the National Committee for Quality Assurance (NCQA).

Remember the three Cs: Efficient medical record keeping facilitates patient management as well as current and future medical treatment. As NCQA says, “Consistent, current, and complete documentation in the medical record is an essential component of quality patient care.” Here are three handy tips that will help you build a foundation for better documentation.

Tip 1: Create a Checklist to Facilitate Consistency

Establish a checklist of basic requirements and make sure that everyone making entries in the medical record knows and follows the list. When constructing your checklist, keep in mind the six core components of medical record documentation, according to NCQA.

• Significant illnesses and medical conditions are indicated on the problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
• Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
• Working diagnoses are consistent with findings.
• Treatment plans are consistent with diagnoses.
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

Pro tip: One way to make sure everyone complies with the checklist is to turn on the function in your electronic health record (EHR) that allows you to view the author of a note “by entry, not by the entire chart,” says Laurie Bouzarelos, MHA, CPC, founder and owner of Provider Solutions Consulting in Centennial, Colorado.

“In most audited charts, there is no indication of who is entering the items in the medical record,” Bouzarelos notes. By turning on this function and using it consistently, you can be sure the author of a note, whether it be a physician, nurse, medical assistant, or scribe, is accountable and meets the standards for documentation.

Utilizing this functionality will help to ensure uniformity across all charts. Plus, it’s consistent with one of the NCQA guidelines suggesting that “all entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.”

Keep track of clinical course: In addition to the six NCQA core elements, “notes should also include information about follow-up care, calls, or visits, if applicable. The specific time frame for all of these should be noted in weeks or months, or as needed,” Bouzarelos suggests. So, you can take another step toward consistency by creating a template for documenting subsequent care and correspondence info.

Tip 2: Encourage Quick Chart Turnaround

Lack of timely signoff on the medical record is “a significant, common problem,” Bouzarelos adds. In her audits, she has found signoffs that range from zero to 58 days, with one audit of 24 charts showing a nine-day average. “Plenty of things can be forgotten or misrepresented over this period of time,” Bouzarelos cautions. That leaves practices open to problems down the road, whether it be with the provision of quality medical care or problems with payment.

Medicare: This echoes the sentiments of the Centers for Medicare & Medicaid Services (CMS). According to the Medicare Claims Processing Manual Chapter 12, Section 30.6.1(A), “The service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record.”

Although CMS guidelines do not set a specific timeframe for signing off, local Medicare Administrative Contractors (MACs) “have offered their own interpretation of what this means,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “For instance, WPS GHA medical directors support [the CMS] concept for all documentation and would offer a reasonable time frame of 24-48 hours.”

State: You should also check out your state’s requirements and guidance for the timely authentication of medical record documentation, as some states provide those requirements.

Tip 3: Always Keep Complete Records

Impress upon your providers the importance of being as scrupulous as possible, especially when documenting details that could affect decision-making, such as allergies, past medical history, and pertinent medical conditions. In addition to helping with consistency, using a checklist also helps you ensure that the medical record is complete.

Audit findings often show that there is no documentation of medication allergies, adverse reactions, or no known allergies (NKA) status, according to Bouzarelos. Using a checklist based on the NCQA core components should ensure allergy documentation.

Remember: If the patient reports no allergies, you still need to make an allergy entry in the medical record indicating NKA. “Pertinent negatives are just as important as pertinent positives. Silence in the medical record should not necessarily be interpreted to mean negative or not applicable,” Moore maintains.