Top Ten Documentation Assessment Findings


June 2, 2014
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The topic of this month’s “Top Ten Revenue Cycle Opportunities” pertains to consistent observations Wipfli makes during our coding and documentation improvement (CDI) assessments about clinical documentation.  We highlight those that represent significant compliance concerns or revenue opportunities.  You can perform a quick self-analysis for your organization by ensuring the answer to the following questions is yes:
 
  1. Does your EHR have built-in mechanisms to prevent inappropriate use that could put your practice at risk?  According to several recent reports by the OIG, EHRs create new vulnerabilities, making it easier to commit fraud.  Concerns related to the authenticity of entries, inappropriate use of copy and paste functionalities, and overdocumentation (e.g., often from “canned” EHR templates) create the appearance of “upcoding” attempts.  We find issues in almost every review we conduct, though most were caused inadvertently.  As a result, we recommend implementing internal policies and procedures to address potential EHR-caused compliance issues and working with EHR vendors to determine whether built-in mechanisms are available to safeguard from compliance risk.
 
  1. Is your clinical staff documenting infusion start and stop times so infusion units can be calculated correctly?  Are providers documenting the need for hydration?  CMS states that the administration begins when the actual drug starts, not upon the insertion of the IV catheter or when the normal saline solution begins to infuse.  The administration ends when either the provider stops the drug or the infusion of the drug is completed.  Records should reflect these start and stop times.  In addition, fluid administration to administer the drug or maintain patency of an access line is incidental hydration and should not be reported separately.  The only exception is if there is a diagnosis of dehydration, and documentation must clearly indicate the need for hydration.
 
  1. Does documentation for E/M services paint a true picture of the visit?  According to CMS, incorrect coding of Evaluation and Management (E/M) services accounts for a significant portion of payment errors, with findings of documentation that support higher or lower levels of service than reported.  We believe the issue is more about insufficient clinical documentation than improper code selection.  E/M documentation that supports a lower level of service is often caused by the following: (1) missing or vague chief complaint, (2) insufficient documentation of the history of present illness (HPI) (e.g., for chronic disease management, the “status” of each condition is often not documented, which also impacts the level of medical decision making), (3) incomplete (or irrelevant) system review (ROS), or (4) unauthenticated past medical/family/social history (PMFSH) (failure to incorporate the nurse’s intake information into the provider’s notes to show they were reviewed and updated).
 
  1. Are you capturing and reporting Annual Wellness Visits correctly?  Many facilities continue to struggle to understand the elements this service includes and doesn’t include.  A common misconception is that this service includes a complete “head to toe” physical exam, which is not the case.  During the course of many coding reviews, we often see evidence of some components of an IPPE/AWV being documented in conjunction with an E/M visit, yet they are not being reported.  To protect your practice from loss of income and productivity, develop internal documentation protocols and educate patients about what to expect at a wellness visit.   
 
  1. When reporting an E/M visit with a procedure or other service (such as preventive medicine) with modifier 25, does your documentation clearly support a “significant separately identifiable E/M service”?  According to the NCCI policy manual, an E/M service is separately reportable on the same date of another service under limited circumstances.  In general, E/M services on the same date of service as a minor surgical procedure are included in the payment for the procedure, including the decision to perform the procedure, and should not be reported separately.  Similarly, an insignificant or trivial problem is not reported or billed separately from a preventive service.  However, significant and separately identifiable E/M services are separately reportable with modifier 25.  To ensure that documentation truly supports separate billing, we suggest the E/M service be recorded as a separate entry from the procedure or preventive service.
 
  1. Are the indications for ordering diagnostic tests and/or procedures present in the medical record, and does the diagnosis support LCD (i.e., medical necessity) criteria when applicable?  Payment denials often occur because of missing orders and clinical support for the medical necessity for the procedure or service.  For example, recent Medicare post-payment reviews for intramuscular injections resulted in payment recoveries because of insufficient documentation of physician orders and documentation of intent/medical necessity for the medication administered.  If not overtly documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.  Exacerbating this, we also see failure to appropriately link specific diagnosis codes to the service to support medical necessity on the claim.  This results in claim denials or adjudication as “patient responsibility” when the service would have been paid otherwise.
 
  1. Are you documenting correctly for discharge day management services?  Discharge day management services (CPT codes 99238-99239) are based on “time.”  Unfortunately, documentation rarely includes the time spent, requiring that the lower code (99238, less than 30 minutes) be used.  When more than 30 minutes is documented, the higher-valued code (99239) can be used.  Also, according to CMS, payment recoveries have resulted because of documentation that didn’t support the fact that face-to-face interaction took place, which also is a requirement. 
 
  1. Does your documentation for observation care support that ongoing physician reassessments are being conducted throughout a given day versus once daily?  Many facilities fail to meet documentation requirements to support observation care service because the documentation fails to show that reassessments after the initial H&P are being conducted throughout the day.  Medicare defines observation as a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or whether they are able to be discharged from the hospital.
 
  1. Does your documentation for administration of single-dose vials of IV and oral contrast include the amount (in units) that was administered to the patient as well as the amount wasted to support billing for the total vial?  Based on our assessments, the total units billed for oral contrast often are not supported because documentation described only the amount administered; it did not state the amount wasted.  For example, documentation states 250 ml of IV contrast was administered; 300 ml was billed.  Documentation also must support the wasted 50 ml in order to bill all 300 ml.
 
  1. Does your documentation of musculoskeletal conditions specify whether the condition was a result of an acute (recent) injury, the late effect of an old injury, or caused by overuse unrelated to an injury?  ICD-9 codes for diseases of the musculoskeletal system are classified by acute (800 series), chronic (700 series), or due to late effect (900 series).  Reporting an ICD-9 code from the 800 series tells the payer that the condition was the result of an accident or acute injury, and in many cases payment will be delayed pending request for information to determine whether another source (e.g., auto or workers’ compensation insurance) may be liable for payment.  We often find that provider’s documentation doesn’t specify this information, creating much more administrative work to get the claim paid.  If documentation doesn’t specify whether the problem was (or was not) caused by an injury, the provider should be queried for more information.  This will be even more crucial with ICD-10.

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