Stethoscope and laptop

CMS and the Office of Inspector General (OIG) are a driving force behind compliance regulations affecting documentation guidelines, coding and billing for all health care entities. Maintaining compliance with ever-changing rules and policies can be an overwhelming challenge for organizations, especially while trying to safeguard high-quality patient care.

A provider’s medical record documentation is one of the most targeted areas by CMS, OIG and other regulatory agencies. The expression “if it wasn’t documented, it wasn’t done” is an effective guideline to follow in regard to medical documentation. As evidenced by heightened audits concluded by CMS and OIG, documentation errors remain prevalent in the health care industry and continue to be scrutinized by regulatory agencies and commercial insurance plans.

Organizations should develop clear plans of action to prepare for a potential audit by CMS or an insurance carrier. The provider’s documentation should tell the patient’s story and support medical necessity in medical record components—including history, current illnesses, examination, assessment and treatment plan—which in turn helps maintain proper coding and billing.

In “2018 Medicare Fee-for-Service Supplemental Improper Payment Data,” the U.S. Department of Health & Human Services (HHS) identified the most common documentation mistakes, listed below:

  • Missing provider signature and/or date (attestation)
  • Illegible documentation
  • Illegible provider signatures without signature logs
  • Insufficient detail in progress notes and/or procedural documentation that doesn’t support CPT and/or ICD-10 insurance claims

The table below represents national figures as published by the HHS on November 30, 2018, of the 2018 Medicare Fee-for-Service improper payment rate from Comprehensive Error Rate Testing (CERT) audits. The claim dates for this data range from July 1, 2016, through June 30, 2017. This data represents documentation and payment errors found through CERT audits that could’ve been recouped from health care entities if found prior to payment by CMS.

The data indicates all health care organizations should have regular documentation, coding and billing audits performed as part of their annual compliance plan. Communication and educational tools for providers and coding staff can be implemented to relate documentation and coding-related issues from routine audits.

2018 Medicare Fee-for-Service Improper Payment Rate from CERT Audits Table

Medical Record Documentation & Coding Audit Process

There are several types of audits to engage depending on the organization’s scope. Once the audit scope is determined, then the necessary documentation is identified and requested. During the audit process, certified coders will analyze the requested records to ensure compliance, accuracy and alignment with the CPT and ICD-10 coding. Typically, the organization should start with an externally performed base audit, which can provide an objective approach to determining potential existing issues. The findings of the initial base audit will determine the next step toward resolution, if necessary. Thereafter, annual routine audits should be implemented along with continued education.

Purposes of Auditing & Monitoring

  • Identify potential documentation and coding risk areas
  • Prepare for medical record and coding audits directed by CMS and insurance plans
  • Ensure compliance of medical policies, regulations, claim procedures and coding guidelines
  • Avoid potential financial loss due to improper payments or recoupments from CMS and insurance carriers
  • Develop ongoing education for providers and coding staff

BKD’s Health Care Performance Advisory Services team is available to collaborate and perform external audits for documentation, coding, billing and revenue cycle assessments. We also provide education to providers and staff to assist with compliancy in all areas. Our focus is guiding health care organizations toward compliant and proficient operations. For more information, complete the form below or explore our suite of health care resources.

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