The Importance of Documentation for Medicare and Medicaid Claims: Part 1 of 2

Dr. Julie Taitsman, Chief Medical Officer for the Office of Inspector General, gave a presentation recently as a part of the OIG’s award-winning HealthCare Fraud Prevention and Enforcement Action Team (HEAT) on the importance of documentation for Medicare and Medicaid claims. The information in Dr. Taitsman’s presentation can help you to better understand the issues surrounding proper medical records documentation in patient medical records and in Medicare claims and bills. This blog post is the first of a two-part series on the topic.

Dr. Taitsman began her presentation speaking about accurate claims:

Providers are responsible to submit accurate medical records for claims to Medicare and other payers, to maintain accurate patient records and to provide adequate backup in order to prove claims.

Submit Accurate Claims

Accurate documentation of medical records provides for program integrity, ensures patient safety and protects the provider:

  • Program Integrity – Accurately documented medical records ensure that payer programs such as Medicare and Medicaid pay the correct amount -- not too much, not too little -- and ensure that the programs pay the right people.  Using an electronic claims submission software on top of all that help ensure accuracy. 
  • Patient Safety – With accurate documentation, patients get good quality of care, which promotes patient safety.
  • Provider Protection – Accurate documentation helps healthcare providers avoid liability and stay out of fraud/abuse trouble.

Why is Documentation Important?

It is part of the Office of Inspector General’s (OIG’s) oversight role to make sure that claims are accurate so that Medicare and Medicaid pay properly. Through their audits, evaluations, investigations and compliance work the OIG has identified seven main kinds of inaccurate or incorrect medical coding and billing: The provider’s claims must be accurate and bill using the correct code, not just the code that offers the greatest reimbursement. If you are confused about which code to use, there is probably a reason there are two options. Don’t assume you know the answer; ask someone who knows the difference.

Promoting Patient Safety

Good documentation promotes patient safety and helps to ensure quality patient care. The “absent-minded professor” excuse (someone who is good at medical care but bad at medical documentation) does not hold water with the OIG. Good documentation provides for the following: Increased Complexity Requires More Accurate Records

Healthcare delivery is becoming increasingly more complex and the quantity of medical data describing the services performed is growing.

  1. Upcoding – using a more expensive code; charging more for an item than is required
  2. Unbundling – billing separately for services covered in a full service fee, e.g., billing separate codes for a surgery and a follow-up visit the next day when one global code already includes both services
  3. Lack of medical necessity – billing for things that are not necessary: if an MRI isn’t documented as necessary, Medicare shouldn’t pay, even if the work was well-done and is accurate
  4. Services not rendered – billing for items or services that were not provided
  5. Worthless services – billing for items or services of such low quality that they are virtually worthless and billing for them is unjustified
  6. Duplicate billing – billing for an item or service two or more times when it was only provided or performed once
  7. Lack of documentation – billing when a medical record cannot or does not back up the claim
  8. Good documentation protects patient health. Failure of documentation is not just a technical paperwork problem; it can actually endanger a patient’s health.
  9. Good documentation ensures the best possible care. Good medical record keeping ensures that the patient gets the best possible medical care from the primary care doctor, but also from other providers who rely on the PCP’s records when treating their patients.
  10. Good documentation prevents duplication. If a patient is referred out to a specialist, accurate documentation ensures that other professionals can see and understand the work that has already been performed.
  11. Good documentation prevents unnecessary medical services. Accurate record keeping prevents subjecting patients to unnecessary medical services and avoids harm, such as giving a patient incorrect medication. Bad things can happen to patients if their medical records are not accurate.
  • Patients are seeing many different doctors, specialists and other professionals.
  • Providers cannot rely on memory. Records must be complete, accurate and legible.
  • Records must be accessible to the entire healthcare team and promote communication to all the providers caring for the patient.
  • Records should be accessible only to the care team and staff legitimately treating the patient.
  • Security systems must be in place.
  • When recorded accurately, medical records are an essential tool in clinical decision making.

This blog post concludes part one of the series. In part two we will discuss how keeping accurate records can protect providers, how the OIG enforces proper documentation, some of the pitfalls of electronic medical records (EMR) and EMR systems’ security issues.  Good documentation is a driving factor in clean claims - make sure you understand the medical claims process to ensure your practices get paid.

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