Its quite common to receive a request for medical records from insurance carrier who is going to conduct an audit on your claims. Sometimes, in such external/payer audits, practices receive audit results like, medical necessity not supported; records include conflicting data; or notes are cloned. Audit report also says practice owes them huge amount of money due to ‘overpaid claims’ and they are putting on pre-payment review until things improve. Practices wonder what went wrong? Because their Electronic Health Record (EHR) system was excellent, coders are good at using right codes, clinical notes were voluminous, patients also achieved great outcomes. In this article, we discussed about avoiding common documentation pitfalls especially three of them: Cloning Medical Records, Conflicting Information, and Overstuffed Progress Note.
Cloning Medical Records
Auditors whether private and public, loves to deny claims based on allegations that the provider simply copied and pasted prior notes. ‘Copy/paste’ type operations that occur without needed modifications to content is a process infamously known as ‘cloning’. And that doesn’t just refer to the entire progress note as a whole; it can refer to pieces of a progress note that are inaccurate. Those pieces could be integral to billing a distinct procedure, or a crucial element associated with an office visit code. If one or more pieces never, or almost never, change from one visit to the next, the auditor doesn’t know if the information simply didn’t change, or may have changed but just wasn’t edited. In most cases, auditors seem to assume the latter.
The presence of conflicting information is another red flag. If the history indicates the patient has severe dementia, but the review of the systems template indicates “All systems were reviewed and negative”, well, that could be a problem. One error of this nature can lead to a reviewer to cast aspersions on the integrity of your note. “What else could be wrong with this chart?”, thinks the auditors. Truth be told, these are usually just innocuous mistakes that do not represent any intent to commit billing fraud but the auditors don’t see it that way. They don’t know if you forgot to revise that review of systems because you’re up until 11:30 pm signing off on your notes, or if you’re trying to pad the record with billing elements. All they know is there is a conflict or redundancy which could represent something fraudulent.
Overstuffed Progress Note
Another pitfall that may come back to haunt you is the overstuffed progress note. This occurs when the sheer quantity of the displayed items seems wildly disproportionate to the nature of the presenting problems. Taken at face value, it would seem that a single, self-limiting medical condition would not normally warrant a complete review of past medical, family, and social history, a full review of systems and comprehensive exam. Although there may be times when circumstances do require a more intensive evaluation than meets the eye, the payers expect this would be the exception, not the norm.
All of this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditor’s head, it colors their perspective. If you happen to be a ‘high volume’ provider with disproportionately more billing of any particular code or modifier, the notion that there must be something disingenuous going on becomes solidified. This thinly veiled ethical challenge can be insulting and infuriating to hard-working providers who would never intentionally submit an unsupported health claim.
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