Effective documentation: Know you’re doing it right
Focus on decision-making process
As every case manager knows, getting claims paid boils down to effective documentation. "Documentation is the key," says health care attorney Kathy Fritz, JD, RN, a former nurse practitioner.
"So much of what we know about the patient and the factors that make a difference in the decision-making process are not documented in the medical record," says Deborah Hale, CCS, president of Administrative Consultant Service in Shawnee, OK. "Extenuating circumstances can make a difference in the decision-making process but are often not documented."
Hale says the team approach is the best way to make sure documentation is recorded accurately. "Case managers are the perfect people to get that done because they are on the front lines and they know what those circumstances are," she argues.
According to Fritz, the way services are rendered and the way case managers evaluate the reasonableness and medical necessity of those services is intimately related to how services are billed and how claims are paid.
For example, when case managers perform utilization review or quality assurance activities, they should evaluate whether documentation exists in the medical record to support not only the medical necessity of the services, but also the level at which those services are billed.
An important role of case managers is to determine whether the services the person is receiving are reasonable and medically necessary, consistent with the person’s health care condition, Fritz says. Case managers generally make this determination by conducting a concurrent review of the documentation contained in the person’s medical record, she says.
Similarly, federal payers that conduct audits of a provider’s billing and payment practices also review a person’s medical record documentation to determine the appropriateness of the services rendered and the level of service billed.
In fact, Fritz says that her experience representing providers in administrative agency actions underlines the fact that when it comes to auditing, federal payers rely almost entirely on documentation.
Unfortunately, physicians do not always appreciate this fact. "I am amazed at how many providers have never had any formal training in proper billing and coding practices, and particularly how documentation is integrally related to those practices," Fritz says.
To the extent that case managers can influence a provider’s documentation practices, they should focus on educating providers about three necessary components for level of service determinations: history, physical, and medical decision making, she says.
According to Fritz, these are the three elements for evaluation and management codes that any payer will look at to justify payment at a particular level of service. If case managers cover these three areas, they have covered the essentials for documentation, she says.
Evaluations of new patients or patients who are first admitted to a hospital are fairly thorough, she says. "Generally, the subsequent documentation tends to be less then complete."
What payers generally require depending on the level of service is that two of these three items must be documented, she adds. On the other hand, if providers are doing a comprehensive evaluation and billing at that level of service, which is likely to be costly, they will expect that all three be documented in some form in the record.
According to Hale, these three factors determine physician reimbursement, but they also can apply to the hospital setting. "If you have history and physical, you are establishing the need for the admission to the hospital," she explains. "If you have medical decision making, you have a lot of the factors that relate to the treatment plan that also contribute to the reason for the hospitalization."
One method that Fritz recommends is encouraging physicians to dictate patient information at the time of or immediately after their patient encounters.
"By dictating, providers significantly enhance their chances at complete documentation," she explains. "This way, it is done timely while they still have the patient’s condition in mind rather then at the end of the day after [they] have seen 20 to 25 patients."
While the dictation itself is not a task for case managers, they often are responsible for reviewing the charts that might include dictated reports. In many cases, it will be case managers who, through their quality assessment activities and reports, will be able to influence and improve a provider’s documentation practices.
"They often have direct access to physicians and likely sit on one or more committees where physicians are present," she says. Certainly, a review of proper documentation practices, as they relate to determinations of medically necessary and reasonable services and billing and coding edits, can be made a part of each monthly meeting where a best practice issue is presented, she adds.
Part 1 of a 2-part series
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