The documentation captured during an encounter becomes part of the patient’s legal medical record. As healthcare providers, we believe one of the medical record’s most critical functions is to plan and provide continuity of care for a patient’s medical treatment.
Healthcare providers need to also remember the additional functions of the medical record, including the following:
- providing information for the financial reimbursement to hospitals, healthcare providers and other sites of service, and patients;
- providing legal documentation in cases of injury or other legal proceedings;
- providing information for quality improvement/assurance and peer-review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and
- providing the critical information in an accreditation process.
The final, legal medical health record is ultimately defined by your organization. Assessing and defining the medical record for complete documentation elements are imperative. Ultimately, auditing documentation to assess the completeness of a medical record, determining the accuracy of documentation, and potentially discovering lost revenues should be a part of your clinical and operational process.
When auditing a medical record, the documentation is examined to determine if it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, compliance with the organization’s policies and procedures, and compliance with payer regulations may not be identified.
In a review of the 2014 Centers for Medicare & Medicaid Services Evaluation and Management Services Guide,1 it states: “Healthcare payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate the site of service, the medical necessity, and appropriateness of the diagnostic and/or therapeutic services provided and/or that services furnished have been accurately reported.”
The Evaluation and Management document1 continues to expound upon the general principles of medical record documentation to help ensure the medical record documentation is appropriate, including the following:
- The medical record should be complete and legible.
- The documentation of each patient encounter should include
- ○ reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
- ○ assessment, clinical impression, or diagnosis;
- ○ medical plan of care; and
- ○ date and legible identity of the observer.
- If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
- Past and present diagnoses should be accessible to the treating and/or consulting physician.
- Appropriate health risk factors should be identified.
- The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
- The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
- In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.
Knowing the principles of medical record information provides the basis for performing an internal audit of the medical record. Specific strategies to consider when performing a wound care audit may include the following:
- reviewing the Fiscal Intermediary’s website for the language that supports wound care services and medical necessity requirements;
- interviewing the staff to ensure a clear understanding of the documentation process and workflow that define the medical record;
- reviewing the policies and procedures that support the department’s work;
- meeting with the compliance officer to review any audits that may have been completed in the wound care department previously, reviewing trends;
- ensuring the patient’s visit is supported by the physician’s order;
- reviewing the most frequently documented procedures, such as debridements or application of cellular and/or tissue-based products for wounds or skin substitutes;
- reviewing the assignment of the CPT®* codes;
- reviewing the documentation for the procedure to ensure it supports the work performed;
- ensuring the procedure meets medical necessity and supports the physician’s order;
- reviewing the number of procedures completed within a given time frame for each patient audited;
- reviewing the chargemaster and summary report/superbill used for billing;
- working with medical records to define “timeliness of documentation” and closing a record;
- following the billing for the services performed from the beginning of the documentation process through the billing process;
- asking about any denials; and
- understanding the denial management process and ensuring the department is a part of this process.
It remains the clinician’s responsibility to understand the documentation elements comprising the legal medical record. Can you define the documentation elements necessary for compliance in your wound care department?
1. Centers for Medicare & Medicaid Services. Evaluation and Management Services Guide. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
. Last accessed March 24, 2015.*CPT is a registered trademark of the American Medical Association