Cardiology Coding Alert


Follow 3 Handy Tips to Ensure Medical Records Are Consistent, Current, and Complete

Hint: Don’t let providers fall behind in signing off on medical records.

If you are not regularly checking in to make sure your cardiologists’ medical records are in tip-top shape, you could be risking poor medical outcomes and losing out on well-earned reimbursement. According to the National Committee for Quality Assurance (NCQA), “Consistent, current and complete documentation in the medical record is an essential component of quality patient care.”

Follow these handy tips to maintain stellar medical records and to keep your practice running smoothly.

Tip 1: Create Checklist for Everyone to Follow

First, you should establish a checklist of core requirements and make sure that everyone making entries in the medical record knows and follows this list. When creating your checklist, refer to the following core elements of medical record documentation, as per the 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.

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-A, contracting and chart auditing specialist at Physician’s Ally Inc. of Littleton, Colorado.

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

This is consistent with one of NCQA’s 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.”

Don’t forget follow-up: In addition to the six NCQA core elements, “notes should also include information about follow-up care, calls, or visits, if applicable. The specific timeframe for all of these should be noted in weeks, or months, or as needed,” Bouzarelos says.

Tip 2: Don’t Fall Behind With Documenting

Missing timely sign off on the medical record is “a significant, common problem,” Bouzarelos says. In her audits, she has found signoffs that show a range from 0 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 with quality medical care and problems with payment.

Medicare: 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,” says 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.”

Don’t miss: You should also check out your state’s guidance and requirements for the timely authentication of medical record documentation, as some states provide those requirements.

Tip 3: Always Keep Complete Records

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.

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 says.