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Importance of Documentation

OIG talks about the Importance of Documentation.

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Hello. I am Julie Taitsman, Chief Medical Officer for the US Department of Health and Human Services, Office of Inspector General.

Why is proper documentation so important? What can you do to make sure your documentation practices are correct? Proper documentation, both in patients' medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider.

Good documentation is important to protect our programs. Accurate documentation ensures the Federal health care programs pay the right amount—not too much and not too little—to the right people.

Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, that's what really matters.

Good documentation is important to protect you the provider. Good documentation can help you avoid liability and keep out of fraud and abuse trouble. If your records do not justify the items or services for which you billed, you may have to pay that money back.

Let's look at two examples where medical recordkeeping was inadequate or inappropriate. This first example is a case of insufficient documentation. That is billing when the medical record cannot back up the claim. Here, a hospital billed Medicare for several imaging services supposedly rendered to a Medicare beneficiary treated in the hospital's emergency room.

When asked to justify the charges, the hospital produced this medical record. This medical record is for an ER visit. It shows a chief complaint and some vital signs. What's missing? There's nothing about the x-rays for which Medicare was billed. There should be a history and physical pointing to the need for the x-rays. There should be a physician's order for the x-rays. There should be an interpretation and result to show someone read the x-rays. And there should also be some indication that a physician treating the patient used those results when planning the patient's care. All of those factors are missing in this record.

When OIG reviews a record like this, we have no way to know whether or not the beneficiary needed x-rays, whether or not the beneficiary actually got the x-rays, and, if he did get the x-rays, whether or not anyone bothered to read the x-rays.

In this example, the hospital billed for services, but the hospital cannot demonstrate that it deserves to keep that money. Better documentation practices could have prevented this problem.

This second example also demonstrates poor documentation practices. We saw a claim where a provider billed Medicare as if a beneficiary had renal failure. We saw no evidence of that diagnosis. So we asked the provider to explain. The provider assured us that the beneficiary did in fact have renal failure, and sent us this page from the medical record to prove it.

The provider directed our attention to the highlighted letters to support the diagnosis of renal failure. Let's focus in on that section. It says "chronic pain, pathology diagnosis, CRI, Renal Cell Carcinoma, refer to oncology." "CRI," an abbreviation for chronic renal insufficiency, is highlighted in yellow.

I should note that the highlighting in the record was done by the provider not by OIG. There is no notation to indicate that anything was added later.

Now this patient had a lengthy medical record, and our audit team had already obtained that page of the record. But in the earlier copy, it just says "chronic pain, pathology diagnosis, Renal Cell Carcinoma, refer to oncology"

So "CRI" was added to the patient's record long after the date on the progress note, after it had already been copied for the audit.

If you discover you billed for chronic renal insufficiency but the medical record does not indicate the patient ever carried that diagnosis, it may be tempting to simply add "CRI" to the record. But don't. The cover-up just makes it worse.

The OIG website is a great resource of more information on how to avoid these problems and make sure this never happens to you.