Denials Chapter 7 Documentation & Med Records Flashcards
Documentation and the Medical Record
A medical record is a repository for an individual’s health information and is kept for planning patient care and providing written communication to all involved in providing patient care. The information contained in the medical record may include information from a nurse, physician, dentist, chiropractor, psychiatrist, or other healthcare provider.
Details within the medical record may include information about medical history (labs test performed, medications prescribed, information about operations, and/or details about lifestyle, family medical history, etc.). Healthcare providers are required to maintain complete and accurate medical records for all services they perform. These requirements are generally enforced through licensing, the certification process, or credentialing with insurance carriers.
The record begins at birth and chronicles diseases, minor and major illnesses, preventive measures taken, and growth progression. Components commonly found in all medical records make each as unique as the individual to whom it belongs:
Each medical record must have a personal identification number assigned to it, which is specific to every individual patient. This ensures accuracy of the details contained within the record and adds a layer of security to prevent unauthorized use.
A patient’s medical history is required to be in the record so healthcare providers can make assessments about a past, current, or future state of an illness. By reviewing what has happened in the past with the patient, a healthcare provider can identify risk prevention for future illnesses. The various types of history that are often involved in the medical record are:
Surgical history details past surgeries that the patient has undergone.
Obstetric history details prior pregnancies, complications, and outcomes.
Medications and allergies include a list of all current medications the patient is taking, as well as any medical allergies that the patient has or has had.
Family history identifies if a patient’s risk to certain diseases or illnesses is increased due to the health status or cause of death of immediate family members.
Social history (habits) describes a patient’s lifestyle, such as tobacco or alcohol use, marital status, employment status, relationships, level of education, etc.
Immunization history describes which diseases a patient has been vaccinated against, if any.
Developmental history is mostly tracked in children and adolescents to ensure they are growing and developing at a medically acceptable rate.
Many medical records will also include a medical directive to allow the patient to communicate their wishes to the healthcare community prior to any event in which he or she may become incapacitated to speak, or to make his or her wishes known in certain medical emergencies.
Medical Record Entries
All medical record entries should be complete and legible and should include the legible identity of the provider and the date of service. Occasionally, a provider will need to amend or correct a medical record entry. When a modification is made to the medical record, the following record-keeping principles apply:
1.Clearly and permanently identify any amendments, corrections, or addenda.
2.Clearly indicate the date and author of any amendments, corrections, or addenda.
3.Clearly identify all original content (do not delete).
When correcting a paper medical record, a single line strike through should be used so the original content is still readable. The person altering the medical record must sign and date the revision, amendment, or addenda.
For electronic health records (EHR), the amendment, correction, or delayed entry must be distinctly identified. There must also be a way to provide a reliable means to clearly identify the original content and the modified content. The person altering the record and the date of the revision, amendment, or addenda must also be documented.
Medical Record Retention Requirements
Medical record retention times generally are governed by the individual states. CMS requires hospitals to retain all patient records for at least five years after the submission of their closed cost reports. For providers who accept the Medicare Managed Care program, the records must be maintained for 10 years. HIPAA rules require HIPAA records to be maintained for six years of the date of its creation, or the date from which it was last in effect (whichever is later).
There are no specific requirements as to how the medical records must be retained. They may be kept in their original format or reproduced in a way that is legally acceptable. The most important component of retention is that the record is protected, to ensure the security and integrity of the records. They should be accurately written, promptly completed, filed, and readily accessible.
While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal.
While there are federal guidelines for records retention as stated above, it is important to remember that if your state laws require longer record retention, the state law will pre-empt the federal regulations.
Basic Medical Record Documentation
Information should be entered in the patient’s chart at the time of service, or immediately following the service, which is typically timelier in the hospital setting due to hospital compliance guidelines. Hospitals may specify a timeline by which documentation should be completed in their compliance manual.
The importance of timely entries is more critical in cases where the patient is undergoing a complicated set of services by different healthcare providers. The patient’s chart becomes a vehicle for communication between the providers and departments involved with the patient’s care. If entries are not made at the time of service, crucial information may be missing when another provider needs to refer to the patient’s chart. This lack of documentation could have a negative impact on the patient’s medical treatment.
Types of Documentation
Medical record documentation can come in many forms, such as handwritten, dictated, templates, or electronic. Each form of documentation has its own risk areas.
Handwritten records are often illegible and abbreviated. In addition, some information may be left off the medical record to reduce the amount of time it takes to write the note.
Dictation, whether it is a pathology report or an operative report, should be an efficient, thorough, and organized method for recording patient information. Although many physicians are moving to electronic health records, many are still using dictation.
Physicians dictating their patient notes must take special precautions. Often, there is a delay between the patient visit and when the information is placed in the chart. It may take several days for the transcriptionist to transcribe the recorded information and return it to the physician, who then reviews it for accuracy, signs it, and places it in the patient’s chart. Any corrections should be made before it becomes part of the record. During this time, it may be necessary for the physician to enter into the chart a written summary of the services rendered on that date. The summary must contain enough information about the patient encounter so that it could be used in place of the transcription in case of loss, misfiling, or inaccuracies. Remember, it must be legible to all readers. Each hospital medical record has a specific section in the chart for nurse’s notes, physician notes, laboratory results, X-rays, orders, etc.
According to Medicare guidelines, the physician must sign dictated notes before they are placed in the patient’s chart. A signature alongside the note indicates the provider has read the transcription and approved the information.
When providers use templates for documentation, they might have check boxes to indicate whether an exam of a body area or organ system is normal. In this case, any findings that are abnormal must have elaboration as to what is abnormal. It is helpful if the provider has a key explaining checklist symbols.
Although electronic health records have great benefits, including the timeliness of documentation, there are also inherent risks. EHRs often have built-in templates that might cause a provider to document more than is medically necessary for that visit. EHRs allow copying or cloning medical records, which can cause many records to look the same and because information to be recorded that did not apply to that visit. When auditing records produced from EHRs, one might see complete medical histories on each visit for the patient or notes that look similar from one visit to the next. It is always important to remember that medical necessity should drive the level of the visit, not the amount of documentation. The Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 confirms this, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”
Date and Time
The date and time should accompany all entries. The time of service is also important, so the events of a patient’s medical treatment may be reconstructed later. A patient who receives one medical treatment, followed by another event and more medical treatment later on the same date, is an example. If the time of the service is significantly different from the time of the chart entry, both times should be documented with an explanation for the delayed entry.
Signatures
Medicare requires a legible description of services to be provided/ordered. The method used (e.g., handwritten or electronic) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Payers have been cautioned against denying a claim on the sole basis of type of signature submitted.
Physicians using alternative signature methods (e.g., a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods. For example, a rubber-stamped signature is much less secure than other modes of signature identification. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested. Physicians should check with their attorneys and malpractice insurers concerning the use of alternative signature methods. CMS no longer allows rubber stamps for signature, but other carriers may.
Many private payers do not require a signature or initials, but because medical records can, and often do, become legal documents, a full signature is generally the best practice.
Electronic signature systems use a code or other means to uniquely identify each physician having access to the system. The physician signs an electronic record by entering his or her code into the system. Congress included provisions to address the need for security and electronic signature standards and other administrative simplification issues in HIPAA, Public Law 104-191, which was enacted on August 21, 1996. The standards have not been finalized. The HIPAA proposed standard would require certain security service features such as message integrity, nonrepudiation, and user authentication. In the hospital setting, the electronic signature is recognized as sufficient to meet documentation requirements. As stated in the CMS Transmittal A-03-021:
1.“Only individuals specified in hospital and medical staff policies may make entries in the medical record. All entries in the medical record must be dated and authenticated, and a method established to identify the author. The identification may include written signatures, initials, computer key, or other code.
2.The parts of the medical record that are the responsibility of the physician must be authenticated by this physician. When nonphysician practitioners (NPPs) have been approved for such duties as taking medical histories or documenting aspects of physician examination, such information shall be appropriately authenticated by the responsible physician. Any entries in the medical record by house staff or an NPP that require counter signing by a supervisory or attending medical staff member shall be defined in the medical staff rules and regulations.
3.There must be a specific action by the author to indicate that the entry is verified and accurate. Any system that would meet the authentication requirements are as follows:
Computerized systems that require the physician to review the document on-line and indicate that it has been approved by entering a computer code.
A system in which the physician signs off against a list of entries that must be verified in the individual record.
A mail system in which transcripts are sent to the physician for review, and then he or she signs and returns a postcard identifying the record and verifying its accuracy.
A system of auto-authentication in which a physician or other practitioner authenticates a report before transcription is not consistent with these requirements. There must be a method of determining the practitioner did, in fact, authenticate the document after it was transcribed.”
Minimum Necessary
The Minimum Necessary Standard is a key protection of HIPAA Privacy Rule. The rule requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose. A covered entity is required to develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary.
When the minimum necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a purpose, unless it can specifically justify the whole record as the amount reasonably needed for that purpose.
For example, when documentation is requested by a payer for processing of a claim, only documentation pertinent to that service should be sent to the payer. Sending the entire medical record would be a violation of minimum necessary.
Medical billers often receive requests for medical records for processing claims. A medical biller should respond to the request for records by providing only the dates of service requested, or the minimum necessary.
Medical Record Requests
Insurance carriers will request medical records when they need additional information to process a claim. The following steps should be followed when a request for medical records is received:
Make a copy of the medical record only for the specific date of service requested.
Review the medical record to make sure the services billed are accurate. If the provider referenced documentation from another area of the record during the encounter, make sure this information is copied and sent with the date of service information.
Document in the computer system indicating a copy of the record was sent to the insurance carrier.
Attach a copy of the medical record claim and the remittance advice.
Send all of the gathered information to the insurance carrier.
Question: My provider is consistently behind in documentation; can I bill for services prior to the provider completing the documentation?
Answer: Many of us already know this familiar phrase: “If it has not been noted in the record, then it never happened.” A procedure must be indicated and substantiated on the chart and included in the EMR for the payers (and auditors) to accept a claim for that service.
Bottom line: Regardless of what procedures the physician performs — and how mandatory or integral it is that the procedure be performed in line with the rest of the documented services — if a particular procedure is not documented, it does not get reimbursed. Period.
Remember: Payers determine eligibility for payment through the documentation submitted to substantiate the claim. Providers should ensure that their documentation accurately and meticulously reflects a full picture of the encounter. This will, in turn, maximize reimbursement and revenue.
