January 22, 2013

CMS Inspector Documenteau on “The Case of the Incomplete Clinical Documentation”

By Gretchen Dixon, MBA, RN, CCS, CHCO, AHIMA Approved ICD-10 CM/PCS Trainer

News from “Inspector Documenteau,” a.k.a. the Center for Medicare & Medicaid Services (CMS), may have reached your desk around November 9 and then again on December 7, 2012, regarding progress notes, amendments, corrections, and delayed medical record documentation. At a recent meeting, I found that Inspector Documenteau is gearing up the team to validate how well medical record documentation supports medical necessity of provided services.

The CMS Transmittal 438 on November 9 documents how the reviewers are to make determinations when using the various types of forms such as Progress Notes, Limited Space Progress Note Templates, Open Ended Progress Note Templates, and other supplemental forms.

Inspector Documenteau’s team consists of organizations we all are familiar with the following:

  • MACs (Medicare Administrator Contractors)
  • CERTs (Comprehensive Error Rate Testing)
  • RACs (Recovery Audit Contractors)
  • ZPICs (Zone Program Integrity Contractors):  This group has a reputation of being the “bulldogs” in this industry, and they are scored based on the amount of overpayments recovered and the number of enforcement actions handled and referred to law enforcement.

How does this affect our daily process for communicating to the provider documenters? Are our providers documenting according to Health Information Management industry standards? Is the documentation thorough, complete, and accurate for the services provided in the medical record (MR)?

Here is a quick synopsis of the information CMS will be looking at:

  • Progress notes created with Limited Space Templates (LSPs): These will not provide sufficient documentation for face-to-face visits and medical examination. The reason for this determination is that these templates often use checkboxes with predefined answers. CMS has consistently discouraged the use of checkboxes in templates and continues to reiterate the reason in their Transmittal communications. It has been discovered that Limited Space Templates (LSPs) fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. Additionally, CMS has noted that the selected information is normally focused on reimbursement; therefore, these documents generally do not provide sufficient evidence to adequately demonstrate medical necessity criteria.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the services; therefore, the entity needs to refer to the Local Coverage Determination policy for additional details.

Limited Space Templates need to be developed allowing optimization for full and complete entry of information supporting that coverage and coding criteria are met.

  • CMNs, DIFs, supplier-prepared statements, or physician attestations: One attendee asked, “Can we use CMNs (Certificates of Medical Necessity), DIFs (DME Information Forms), supplier-prepared statements, or physician attestations by themselves as medical necessity documentation?” The Inspector shouted, “No, you cannot!” None of these documents “provide sufficient documentation of medical necessity even if signed by the ordering physician.[i] And none of these types of documents will be considered by my team when making a coverage or coding determination.”
  • Financial liability for ordered services provided by another entity: Physicians and Licensed/Certified Medical Professionals (LCMPs) need to be aware that when ordering a service to be provided by another department, organization, or business, there are specific requirements to be documented. The documentation of information in the order must be adequate to support the medical necessity of the service to be provided by the entity at the time the order is documented. Failure to provide this documentation from a supplier’s request may trigger increased monitoring of the provider’s Evaluation & Management services.

  • Amendments, corrections, or delayed entry changes: The December 7 Transmittal 442 was related to amendments, corrections, and delayed entries in a medical record. Initially, the CMS representative covered principles for record keeping, noting the format was not important (e.g., paper or electronic). However, documents submitted to the reviewers containing amendments, corrections, or delayed entry changes must:
    • Clearly and permanently identify the entry,
    • Clearly indicate the date and author of the entry, and
    • Not delete but instead clearly identify all original content.

Corrections: The Inspector also described how these corrections should be made in both the paper medical record (MR) and the electronic health record (EHR):

  • Paper MR corrections should be completed by striking a thin single line through the original entry, while making sure the original content can still be read. To this, the corrected information, the author of the alternation’s signature, date of the revision, and reason for correction should be added.
  • Electronic Health Records (EHRs) must follow the same standards as paper MR corrections. In addition, systems/programs must be able to distinctly identify any corrections and provide a reliable means to clearly identify the original content and the modified content, as well as the date and authorship of the original and for each modification of the EHR.

If any member of the review team identifies medical record documentation with potentially fraudulent entries, the reviewers/auditors shall refer the cases to the ZPICs, which may refer the case to the Regional Office or State Agency.

Takeaways

My takeaway is this: Don’t delay. Conduct a sample review of the current process for these areas and determine the risk liability for the organization, with a strong possibility of involving the Compliance Department. Then we will be able to validate we are following industry standards as documented by our professional organization, AHIMA (American Health Information Management Association), titled: Legal Documentation Standards. This information can be located on its website: www.AHIMA.org.

Policies and procedures related to this information may have to be updated. In addition, the internal audit team will need to add a focused audit objective relating to these topics ASAP to determine the current level of compliance. There is always work to be done, but we need to work smart and be as effective and efficient as possible.

Let’s go to work!

About the Author

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

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[i] Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions; 3.3.2.1.1.B Guidelines Regarding Which Documents Review Contractors Will Consider