{"id":7774,"date":"2022-04-29T17:05:02","date_gmt":"2022-04-29T11:35:02","guid":{"rendered":"https:\/\/www.medisysdata.com\/blog\/?p=7774"},"modified":"2022-11-02T14:14:15","modified_gmt":"2022-11-02T08:44:15","slug":"avoiding-common-documentation-pitfalls","status":"publish","type":"post","link":"https:\/\/www.medisysdata.com\/blog\/avoiding-common-documentation-pitfalls\/","title":{"rendered":"Avoiding Common Documentation Pitfalls"},"content":{"rendered":"

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 \u2018overpaid claims\u2019 and they are putting on pre-payment review until things improve. Practices wonder what went wrong? Because their Electronic Health Record<\/a> (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.<\/p>\n

Cloning Medical Records<\/h2>\n

Auditors whether private and public, loves to deny claims based on allegations that the provider simply copied and pasted prior notes. \u2018Copy\/paste\u2019 type operations that occur without needed modifications to content is a process infamously known as \u2018cloning\u2019. And that doesn\u2019t 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\u2019t know if the information simply didn\u2019t change, or may have changed but just wasn\u2019t edited. In most cases, auditors seem to assume the latter.<\/p>\n

Conflicting Information<\/h2>\n

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 \u201cAll systems were reviewed and negative\u201d, 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. \u201cWhat else could be wrong with this chart?\u201d, 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\u2019t see it that way. They don\u2019t know if you forgot to revise that review of systems because you\u2019re up until 11:30 pm signing off on your notes, or if you\u2019re trying to pad the record with billing elements. All they know is there is a conflict or redundancy which could represent something fraudulent.<\/p>\n

Overstuffed Progress Note<\/h2>\n

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.<\/p>\n

All of this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditor\u2019s head, it colors their perspective. If you happen to be a \u2018high volume\u2019 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.<\/p>\n

Medisys Data Solutions<\/strong> is a leading medical billing company providing complete billing and coding services for various medical billing specialities. To know more about our medical billing and coding services<\/a>, contact us at info@medisysdata.com\/ 302-261-9187<\/p>\n

Reference: Coding audits 101: How physicians can prepare<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":7775,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"categories":[3],"tags":[241],"class_list":["post-7774","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-medicalbilling-medicalcoding-healthcare-physician-patient"],"yoast_head":"\nAvoiding Common Documentation Pitfalls<\/title>\n<meta name=\"description\" content=\"In this article, we discussed avoiding common documentation pitfalls, especially three of them: Cloning Medical Records, Conflicting Information, and Overstuffed Progress Note.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" 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