Maintaining Accuracy and Compliance in the Medical Record

What constitutes a medical record and what are the primary purposes of the medical record?
The definition of a medical record is:

electronic or paper documents containing factual information regarding a patient’s health status and the corresponding medical opinions based on that information

A patient’s medical record serves multiple functions. First, it provides a method of clinical communication and care planning among healthcare practitioners, employers, payers and patients. Second, the medical record indicates the basis for evaluating the adequacy and appropriateness of care. The medical record must include all supporting documentation for the reimbursement of services provided. (i.e., Results from ordered tests including, but not limited to x-rays, labs, communication from other providers involved in the patient’s care, etc.) In addition the medical record provides protection of the legal interests of the patient, facility and healthcare practitioners. Finally, the medical record is utilized as clinical data for the purpose of research and education.

Accuracy and Compliance

Why is accuracy and compliance to accepted standards of documentation in the medical record important? The first and most important reason is to provide patients with appropriate care based on details provided in their medical record. This ensures optimal patient care and allows for excellent patient satisfaction. Another reason for ensuring accuracy and compliance in the medical record is to provide governmental agencies, and any other entity accessing the patient’s medical record accurate and complete information.

With improved documentation, collections improve, the risk for unfavorable audit results decreases, and efficiencies are increased in the office with both staff and physician co-workers.

What should be included

The medical record should include documentation of the medical history, exam, and medical decision making involved in the treatment of a patient. The medical record serves to justify the reason for the medical care provided, with the medical necessity clearly indicated. Accurate reimbursement flows from these components. Additionally, the medical record is commonly used to share information between providers and assess quality of care.

Chart Auditing and Documentation Standards

The medical record must be complete and legible. Each encounter must be able to stand alone by providing:

• Reason for encounter (Chief Complaint)
• Relevant history, exam findings, and current and prior diagnostic test results
• Assessment and clinical impression with regard to diagnosis(s)
• Plan of care
• Date and legible identity of observer

Clinical Protocols

Chart Auditors will often request facility clinical protocols for documentation. Clinical protocols for dictation need to be established for the practices to ensure all details are dictated and abbreviations are followed by policy. For example, if a provider writes “HTN” when a patient has benign hypertension, there would need to be a protocol written for the office personnel stating when “HTN” is written in the patient’s chart or on a fee ticket, it is to be coded as benign hypertension unless further specified. If no protocol exists and “HTN” is documented, the appropriate way to code HTN would be hypertension unspecified.

On handwritten notes, errors are to be corrected with a single strike-through line that is initialed, dated and identified as an error. White-out products should never be used to correct errors, as errors corrected in this manner would be questioned in a court of law.

Compliance audits

Compliance audits for review of documentation also concentrate on additional areas. These include:

• Patient Identification
• Dates and time that care is delivered
• Conclusions- Statement from visits and statements from exams
• Missed and Rescheduled appointments
• Noncompliance with treatment plans
• Coding accuracy which reflects the treatment rendered

How important are Chart Audits

Chart Audits offer a method to improve compliance and reduce risk within a medical practice. Successful documentation improvement is achieved through education of the healthcare professional, systems and record design for facilitation of complete, accurate, timely and legible patient records. Utilizing the recommendations from the chart audit not only improves compliance with improved documentation processes but also assists in appropriate revenue capture.

The OIG (Office of Inspector General) has worked tirelessly to assist healthcare providers in creating their own office compliance program in order to combat fraud and abuse and ensure excellent patient care. The OIG has identified 7 fundamental elements to creating an effective compliance program. They are:

1. Implementing written policies, procedures and standards of conduct
2. Designating a compliance officer and compliance committee
3. Conducting effective training and education
4. Developing effective lines of communication
5. Enforcing standards through well-publicized disciplinary guidelines
6. Conducting internal and external auditing
7. Responding promptly to detected offenses and developing corrective action(s).

The OIG states that an ongoing chart evaluation process is critical to a successful compliance program. Any chart audit reports created by the ongoing monitoring of providers documentation, including reports of suspected noncompliance, should be maintained by the compliance officer within the practice and reported to senior management and/or the provider(s) involved to ensure appropriate education and training is initiated and maintained.

The extent and frequency of chart audits will vary based on factors such as the size and number of providers verses the time, employee(s) trained to audit, and the expense involved if outside auditors are required. Other factors which may influence the extent and frequency of chart audits are the office’s prior history of noncompliance and risk factors present for current violations.

With this in mind, the following recommendations for developing your organization’s own chart auditing program will provide physician practices a baseline for getting started.

• Determine who will perform the chart audits.It should be a top priority to ensure a qualified person review the providers’ documentation. The person should be a Certified Coder through the American Academy of Professional Coders (AAPC) or the American Hospital Information Association (AHIMA) and be well versed in medical terminology. For this reason, it is helpful if the auditor has some clinical background or has worked in the medical field long enough to have a good understanding of medical terminology.
• Determine when and how often charts will be selected for documentation reviews.
• It is recommended that chart audits be completed on a regularly scheduled basis. (i.e., Weekly, bi-weekly, or monthly)
• If the practice has a large number of providers, the providers selected for each audit may be staggered. (i.e., 4 provider charts one week and another 3 providers the following week.)
• It is further recommended that 2 to 3 charts be audited per provider preferably with a mixture of code levels or types of service. (i.e., Preventive visit, sick visit, procedures, etc.) The goal should be to review approximately 5 – 10 charts per provider per month.
• Governmental sample size recommendations:
  • OIG Compliance Plan Recommendations
  • 5-10 medical record per Federal Payer
  • 5-10 medical records per physician
• Corporate Integrity Agreements (CIAs) Recommendations
  • 6 per physician (3 inpatient/3 outpatient)
  • Audits are performed retrospectively, remotely, preferably within 30-90 days of date of service.
• Track the progress of your providers. This may be completed by graft, hand-written notes, an excel spreadsheet, or on a word document. Tracking the provider’s progress or lack there of, provides feedback to both the providers and staff management.
• Monitor which provider(s) need further education on documentation and code selection and record when training was provided. Make a habit of recording when the provider education was provided and complete a follow-up audit in one week to make sure improvement is noted.
• Be sure to encourage and praise the providers, especially those who improve their chart documentation.
• Form a baseline of their normal charges at the beginning of your program and report back to them the additional revenue they incurred as a result of coding correctly.

Finally, if your practice is audited in the future by an actual payer or governmental agency, you have written, substantiated proof that your facility has made a sincere effort to assist your providers in documenting and coding appropriately. Thus by implementing your chart auditing program, you are one step closer to meeting your organization’s OIG recommended compliance plan.

Submitted by Joyce Ralstin CCS-P, CPC