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EDITOR’S NOTE: This is the last installment of a two-part series.

As I wrote in part one, of this two-part series, it always amazes me how naïve physicians can be when it comes to documentation in the medical record. Certain things they should write in a patient’s chart they sometimes do not, and things that should not be part of the chart they sometimes feel obligated to enter.

Clinical documentation is important because it is critical to patient care. One key factor is that the patient’s chart serves as a legal document used for quality reviews and data utilization. The chart also validates the care provided, and well-documented medical records reduce the work of claims processing as well as maintaining compliance with Centers for Medicare & Medicaid (CMS) regulations and other payers’ regulations and guidelines.

Documentation also impacts coding, billing and reimbursement. Let’s take a look at CMS and for what the RAC auditors are looking. Medical necessity is of the utmost importance in this area. There is nothing a RAC likes better than to deny – and why is that, you may ask? They have a stake in denying because, as you may know, they receive a percentage of the spoils of their findings. It kind of reminds one of the old pirate movies: To the victors go the spoils. Here now is the final case to consider when we look at some things that do not belong in the documentation.

The patient had been admitted to another acute facility and then transferred – and the accepting facility’s physician chose to document that the patient was transferred for “medical clearance prior to nursing home placement.”

In the history, the documentation states that the patient had no thoughts of hurting himself and had arrived by private vehicle. Yet this patient was admitted to OBS per documentation of blood sugar (BS) at 261 and also questionable dehydration.

The H&P documented that the patient’s mucous membranes were warm and pink, but the high BS aside, all other labs were within normal limits.

The RACs also have found that 35 percent of reviewed admissions are incorrectly coded. As one can discern from the above percentages, the medical necessity errors outnumber the erroneous coding assignments.

So what should physicians do in order to make sure that the documentation matches admission status and/or code assignment?

  • Complete legible chart entries.
  • Ensure that all entries are dated and authenticated by physician/provider.
  • Provide documentation of each patient encounter.
    • Include a date and reason for each encounter.
    • Record appropriate H&P and prior diagnostic test results.
    • Perform and document review of lab, X-ray data and other ancillary services.
    • Document assessment and plan of care (discharge plan).

Also remember:

  • Codes reported should reflect the documentation.
  • Past and present diagnoses should be accessible to the treating or consulting physician.
  • Reasons for, and results of, all X-rays and labs should be documented.
  • Relevant health risk factors should be identified.

History of smoking, allergies, vaccines not given to Medicare, eligibility, etc. all should be determined.

  • Documentation should support the diagnosis and describe the patient’s treatment.

The quality of clinical documentation impacts both hospital reimbursement and quality-of-care measures. This also impacts severity of illness. Why is it important to capture severity of illness? Because it lends to the patient’s risk of mortality and the intensity of services given.

Please remember, “If it was not documented, it was not done.”

About the Author

Denise Nash, MD, is the revenue cycle director for Quorum Health Resources, LLC. Dr. Nash has more than 20 years experience in the healthcare industry. She has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans.  Denise has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and Value Based Purchasing programs.  Currently she is employed in the ICD-10 division of healthcare consulting in Revenue Cycle for Quorum Health Resources.

Contact the Author


To comment on this article please go to editor@racmonitor.com

Click to read Part 2 – Docs and Documentation: What Should Not Be There – Pt. 1

Region D RAC hits $1 Billion in Corrections


Denise Nash, MD, CCS, CIM

Denise Nash, MD has more than 20 years of experience in the healthcare industry. In her last position, she served as senior vice president of compliance and education for MiraMed Global Services, and as such she handled all compliance and education needs, including working with external clients. Dr. Nash has worked for the Centers for Medicare & Medicaid Services (CMS) in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and Physician Quality Reporting System (PQRS) management to improve financial performance for risk-based contracts and value-based purchasing programs. Dr. Nash has past experience with episode-of-care data, hierarchical condition categories (HCCs), and patient management in the Accountable Care Organization (ACO) environment. She has also worked with both hospitals and physician practices on the legal and financial aspects of adding new services to their respective facilities. Dr. Nash is a consultant on coding/compliance audits at physician practices and hospitals, and has worked for insurance plans conducting second- and third-level appeals. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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