Wiki Incomplete Physician Notes

[molisa]

Opinons and commentary on this issue please!

Our hospital employs multiple physicians for which I am the billing and coding manager. One particular physician routinely fails to complete and/or sign off of his notes. We currently have six pages of unsigned/incomplete notes dating back to January 2011. There are also incomplete notes from prior to 2008 when we implemented an EHR. I have notified our Compliance Officer of this several times, the CEO, the CFO - AND the physician that this is a compliance issue and needs to be addressed. The CEO feels that, as the employer, this is not a concern of ours since it does not relate to employment contracts. Am I wrong thinking that it is a major concern of the hospital's as the physician bills under their group number?

Thank you for any insight you can provide.

 

[Love Coding!]

Opinons and commentary on this issue please!

Our hospital employs multiple physicians for which I am the billing and coding manager. One particular physician routinely fails to complete and/or sign off of his notes. We currently have six pages of unsigned/incomplete notes dating back to January 2011. There are also incomplete notes from prior to 2008 when we implemented an EHR. I have notified our Compliance Officer of this several times, the CEO, the CFO - AND the physician that this is a compliance issue and needs to be addressed. The CEO feels that, as the employer, this is not a concern of ours since it does not relate to employment contracts. Am I wrong thinking that it is a major concern of the hospital's as the physician bills under their group number?

Thank you for any insight you can provide.

Hi Molisa,

I am a Coding Compliance Coordinator. At times I also have these issues with my physicians. Although there is no mandated time frame for completing or signing off physician notes, I do tell my physicians that the notes need to be completed and signed within 72 hours.

Compliance plans to my understanding are not mandated but will be soon. You are thinking in the right direction towards compliance.

What these physicians do not understand is that this is not only a compliance liability it is also a patient liablility. When notes are not signed, they are not valid. The medical record is a legal document.

What if say the OIG or ZPIC decided to pull patient records, the charges the physicians bill for would be considered fraudulant because there is no records to support the visit much less the charges billed.

If I were you, I would keep dates, times and who you spoke to regarding this compliance issue. If this company is not willing to cover their hineys and least you will be able to.

Good luck!!!

 

[molisa]

Thanks for your help. I did keep emails alerting the compliance officer and the one response, which was "Gee, thanks." The lack of patient information is one of my big concerns as some patients have 3-4 missing notes. Not sure how that will stand up in court if there's a problem either.

 

[mitchellde]

Opinons and commentary on this issue please!

Our hospital employs multiple physicians for which I am the billing and coding manager. One particular physician routinely fails to complete and/or sign off of his notes. We currently have six pages of unsigned/incomplete notes dating back to January 2011. There are also incomplete notes from prior to 2008 when we implemented an EHR. I have notified our Compliance Officer of this several times, the CEO, the CFO - AND the physician that this is a compliance issue and needs to be addressed. The CEO feels that, as the employer, this is not a concern of ours since it does not relate to employment contracts. Am I wrong thinking that it is a major concern of the hospital's as the physician bills under their group number?

Thank you for any insight you can provide.

We fixed this in the facility I worked in by coding and billing from only the completed and signed notes. No notes..No codes..No reimbursement. It was a very effective strategy.

 

[kevbshields]

Debra has a very strong point. For too many years now, we've allowed (as an industry and profession) physicians to use encounter forms as the basis of our charges and claims. The problems that have existed for years have not gone away with the implementation of electronic records and the reason for that is provider negligence in supplying quality care--which includes making clinical observations and documents valid in the record.

I say all that to point out that if we eliminated paper encounter forms (superbills, charge slips, etc) from our organizations, we would find that the codes listed on the claim would more closely match that supported in the record; we'd also discover that documentation quality would be positively impacted in that a lack of sufficient documentation results in a lack of charges for service. In all, if we are going to continue to employ encounter forms in our practice or hospital, making those electronic allows them to be kicked back to the provider when a record entry does not exist to support the encounter form, the record is unauthenticated or incomplete, or questions arise that need addressed prior to claim creation. This supports and mandates a more document-to-claim-to-charges-compliant environment and usually solves the problem of delinquent records posing such a risk.