Effective documentation: Know you’re doing it right
May 1, 2002 3 minutes read
Effective documentation: Know you’re doing it right
Focus on decision-making process
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."
According to Fritz, the way services are rendered and the way billing personnel 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 billing personnel 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 billing personnel 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. Billing personnel generally make this determination by conducting a concurrent review of the documentation contained in the person’s medical record, she says.
Federal auditors rely heavily on documentation
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 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 billing personnel 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 billing personnel 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."
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