The Centers for Medicare and Medicaid Services (CMS) closely scrutinizes hospitals and physicians to identify healthcare fraud and abuse. The actual target is not the quality of care, but the documentation that supports why a particular service or procedure was offered. CMS has contracted various organizations, collectively known as recovery audit contractors or RACs to conduct audits for reviewing the claim documents and impose penalties if fraudulent claims are detected. Physicians and hospitals should carry out their documentation effectively via accurate medical transcription to comply with CMS requirements and survive RAC audits. Here are some effective tips for that.
Detailed and Specific Documentation
You should document everything clearly and specifically without skipping any details. Patient medical records should address and/or reflect the following very clearly:
- Admission status, inpatient or observation care
- Primary diagnosis of patient’s condition
- Medical co-morbidities
- Severity of patient’s illness
- Intensity of the service rendered
- Date and time of service
The medical record must also indicate why hospitalization is required instead of a lower level of care. In order to meet the requirements of all patients that you see everyday, prepare bigger, better progress notes. Include the following while structuring progress notes:
- Significant interval history
- Review of systems
- Physical examination
- Summary of diagnostic studies
- Impressions (diagnoses)
- Medical decision making
- Plan
Lastly, all entries in the medical record including the progress notes, dictations and orders as well as documentation from nurses, physical therapists, dieticians and other health professionals must be dated, timed and authenticated by the provider ordering or delivering the service.
Expand SOAP Notes
Your SOAP notes need to be expanded to include the details more clearly. The patient quotes and opinions can be added in the Subjective section. Use reproducible and supportive medical data and document all the treatment options discussed with your patients. This would be helpful as additional documentation and will add more credibility when filing your claims.
Timing
Good timing is very important for your documentation workflow. Avoid delays as much as possible. While history and physical notes should be signed within 24 hours after seeing the patient, operative notes should be documented and signed within 24 hours after the operation. You should complete the medical records within a week of the patient’s discharge.
Avoid EHR Shortcuts
It is better not to use EHR shortcuts such as copying and pasting information and pick-lists for documenting patient records. If you depend completely on them, it will result in selective and restricted documentation. Frequent copy-pasting may lead to inadvertent errors as well. Your documentation must be patient-specific. You can expect greater scrutiny for patient specificity in 2015 and beyond as the Office of Inspector General (OIG) has rebuked RACs for not giving enough attention to this issue. Customize your EHR to deal with this.
Thorough Review
Always double check the data entered into your EMR. Identifying the discrepancies before they are a part of electronic records is very important as it is quite difficult to trace the errors from numerous templates. Physicians should check the accuracy of their medical records before signing them.
Hire Trained Staffs
Since the documentation is extensive, detailed and the most critical component across the care continuum, the best option is to hire skilled and trained transcriptionists to handle and maintain your documentation. You can save a lot of time and effort with this. Reliable medical transcription companies provide the service of proofreaders and editors to review and edit the transcripts produced and ensure the accuracy of your documentation.
