- Medicare Conditions of Participation
- OIG Compliance Plan Guidance Referral to Record Documentation
- Characteristics of Good Documentation
- Assumption Coding as it Applies to Physician Documentation
- The Physician Query Process
- Medicare Conditions of Participation (top) The Conditions are a good guide for requirements for physician documentation in a patient medical record. These are the minimum documentation guidelines for hospitals who participate in the Medicare program. They generally state that every patient record must contain documentation of:
- a physical examination (performed not more than 7 days prior to admission or within 48 hours of admission)
- a health history (elicited from the patient not more than 7 days prior to admission or within 48 hours of admission)
- admitting diagnosis
- results of all consults
- appropriate findings by clinical/other staff involved in the patient’s care
- complications, hospital acquired infections, unfavorable reactions to drugs and anesthesia
- properly executed informed consent forms for procedures and treatments
- all practitioners orders, nursing notes, reports of a treatment, medication records, radiology and laboratory reports, vital signs
- discharge summary which includes: outcome of hospitalization, disposition of case and provisions for follow up care
- final diagnosis with a completed record within 30 days of discharge
- OIG Compliance Plan Guidance Referral to Record Documentation (top) In the OIG Compliance Guidance, the OIG refers specifically to certain documents within the record that may be referenced for correct and complete coding. These include:
- Reasons for patient encounter
- History and physical
- Progress notes
- Treatment plan
- Referrals and consultations
- Patient education
- Recommended follow up care
- Documented rationale for services
- Documentation supporting medical necessity
- Test results
- Relevant health risk factors
- Prescriptions
- Characteristics of Good Documentation (top) In addressing physicians’ and other clinicians’ documentation in a patient’s health record, the following characteristics should be reviewed:
- Legibility Illegible documentation can be reason to deny payment for services as well as to provoke possible quality issues with the care of the patient.
- Completeness To determine completeness of documentation, you need to ask the following questions:
- does the information flow logically
- are there any information gaps
- are there abnormal test results without explanatory documentation
- is there conflicting documentation in the patient record
- are there any required reports that are missing
- Timeliness Timeliness is prescribed by regulations and laws. For example, certain documents need to be in the patient’s record within 24 or 48 hours. Timeliness of documentation affects the quality of patient care. If important information that other clinicians treating the patient need to know to take proper care of the patient is missing - there could be disastrous results.
- Authentication Physicians’ (and other clinicians treating the patient) signatures are required on all their own documentation. As well, physicians need to co-sign and often document more detailed information along with documentation for other clinicians whose work they are responsible for. This applies, for example, to residents and interns in teaching facilities.
- Corrections and Alterations It is important to address making corrections and alterations in patient records. Because of human error, it is inevitable that clinicians will make mistakes. In general, when an author makes an error, it should be corrected in the following manner:
- put a line through the documentation made in error (the line should allow the documentation to show through - don’t smear it out or cross it out completely)
- write the word error above the line
- initial and date just after the word error
- finally, erasures, whiteout or other cover-up techniques should never be used in patient medical records - they call in to question the credibility of the entire record.
- Assumption Coding as it Applies to Physician Documentation (top) The OIG defines assumption coding as "assuming (and coding) from the clinical evidence on the patient’s record that the patient has certain diagnoses in the absence of the physician’s explicit documentation of the diagnosis." Assumption coding is a forbidden practice among coders.
- The Physician Query Process (top) The physician query process involves asking a physician to clarify inconsistent, vague or otherwise unclear documentation about a patient’s diagnosis. The physician query process should only be triggered when there is a problem with documentation quality and there are clinical triggers that act as "clues" to guide the coder in the query process. Some guidelines for the physician query process include the following:
- Ask only questions that are drawn from the clinical documentation that the physician has provided in the patient’s record.
- Ask only open-ended questions if possible. If not, provide reasonable choices for the physician, so it does not appear that you are showing preference for a particular response.
- Never make any clinical assumptions - clinical documentation is solely the job of the physician.
- Remember your role in the coding/billing function is to translate the physician’s documentation into billable "coding" language.
- Like any translator, it is appropriate to ask for clarification, but you need to stick to as strict and literal as possible interpretation of the physician’s documentation.
In other words, assumption coding occurs when the coder "assumes" certain facts about a patient’s condition although the physician has not specifically documented the level of detail that the coder is coding.
An example of assumption coding would be when a patient is admitted with pneumonia and the physician documents the condition as "pneumonia." The coder notes that a C&S was performed that revealed some gram negative rods in the culture. And, the patient is chronically ill and immunocompromized – conditions commonly found in patients with gram negative pneumonia. In this case, the coder would be engaging in assumption coding if s/he coded the patient’s pneumonia as gram negative pneumonia – in the absence of clear cut documentation from the physician that the patient’s case was gram negative pneumonia.
Coders can avoid assumption coding traps by using the physician query process, described below.
