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In its October Medicare Quarterly Provider Compliance Newsletter, the Centers for Medicare & Medicaid Services (CMS) recommend that clinical and administrative staff work together to ensure that all medical records are comprehensive and accurate. Achieving that goal may require a refresher course for some physicians and other providers who actually complete the documentation.


Listed below are a few proactive steps that hospital managers may want to take toward achieving that goal.


Inconsistent, Incomplete, Contradicting Information


According to CMS, RAC demonstration reviewers frequently discovered inconsistent medical record entries. The lesson here is that providers must ensure that all parts of the medical record are consistent, which includes (but isn’t limited to):


  • Assessments;
  • Treatment plans and physician orders;
  • Nursing notes;
  • Medication and treatment records; and
  • Other facility documents such as admission and discharge data, pharmacy records, etc.


In addition to inconsistent entries, providers also failed to adequately document significant changes in the patient’s condition or care issues that in some instances impacted the review determination.


Contradicting information also may cause a red flag, and it, like the above, may be easily rectified. Specifically, if an entry is made that contradicts previous information, documentation that explains the reason for that contradiction should be included. In addition, any information that affects billed services that is acquired after physician documentation is complete must be added to the existing documentation in accordance with accepted standards for amending medical record documentation.


Basic Rules


The medical record must contain sufficient documentation to demonstrate that the beneficiary’s signs and/or symptoms were severe enough to warrant the need for inpatient medical care. (More detailed information about this can be found in Chapter 6, Section 6.5.2 of Medicare’s Program Integrity Manual at http://www.cms.gov/manuals/downloads/pim83c06.pdf.)


Any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary should be documented. Factors that may result in an inconvenience to a beneficiary or family do not, by themselves, justify inpatient admission. Inpatient care rather than outpatient care is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting.


There are several factors that providers should consider when making the decision to admit. For example:


  • The severity of the signs and symptoms exhibited by the patient;
  • The medical predictability of something adverse happening to the patient;
  • The need for diagnostic studies; and
  • The availability of diagnostic procedures at the time when and at the location where the patient presents.


Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital. (See Chapter 1, Section 10 of the Medicare Benefit Policy Manual at http://www.cms.gov/manuals/downloads/bp102c01.pdf.)


Documentation that is not legible has a direct affect on the RAC reviewer’s ability to support that the services billed were medical necessary and were provided in an appropriate setting. CMS encourages providers to ensure that all fields on documentation tools (such as assessments, flow sheets, checklists, etc.) are completed, as appropriate.



If a field is not applicable, CMS recommends that providers use an entry like “N/A” to show that the questions were reviewed and answered. Fields that are left blank often lead the reviewer to make an inaccurate determination.


Final Word


Last but not least, CMS encourages providers to comply with Medicare’s inpatient hospital policy and the AHA Coding Clinic guidance. In the absence of a specific Medicare policy, Medicare contractors may use clinical review judgment to assist in making a payment determination (See the Medicare Program Integrity Manual, Chapter 3, Section 3.14 at http://www.cms.gov/manuals/downloads/pim83c03.pdf .)


About the Author


Barbara Vandergrift, RN, BSN, MA, is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®), St. Paul, MN. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that will equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.

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