Saturday, January 2, 2016

DOCUMENTATION RISKS : Queing up the record for compliance in 2016……….

Lori-Lynne A. Webb
December 10, 2015

As we prepare for 2016 New Year, there are some challenges left over from 2015 that may need to be reviewed and met.  CMS and some of the "big payers" have identified a few of the issues in 2015 post ICD-10 that need some improvement.  As we are well aware, documentation continues to be a challenge.  Below outlines some of the "risks" that were identified and then the opportunity to implement some of the que/review plans and ideas.  The review can bring to light problematic areas and some possible solutions for not only coders, but for your physicians, providers, clinical and office staff.

Risk:   The record(s) does not contain a legible signature with credential.

Que/Review:  Per CMS' requirements in the Medicare Program Integrity Manual ; Chapter 3 – ( Verifying Potential Errors and Taking Corrective Actions) Signature Requirements that was just updated and implemented 08/25/2015,  "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable."    The instructions from CMS are specifically for CMS, however, these instructions from CMS can easily be put into place as a valid process for all signature authentications for a "best practice" in your office.

In addition, providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process. The signature authentication process described below should also be used for illegible signatures.

A. Handwritten Signature
A handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance or obligation.

B. Signature Log
Providers will sometimes include a signature log in the documentation they submit that lists the typed or printed name of the author associated with initials or illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document. Reviewers should encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials. Reviewers shall consider all submitted signature logs regardless of the date they were created. Reviewers are encouraged to file signature logs in an easily accessible manner to minimize the cost of future reviews where the signature log may be needed again.

C. Signature Attestation Statement
Providers will sometimes include an attestation statement in the documentation they submit. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.

Should a provider choose to submit an attestation statement, they may choose to use the following statement:
“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]__when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

D. Signature Guidelines

Meets Requirements
Legible full Signature

Legible first initial and last name

Illegible signature over a typed or printed name  (example)
   John Doe Smith, MD 


Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the signatory.   Eg: illegible signature appears on a prescription.  The letterhead of the prescriptions lists (3) physicians' names, one of the names is circled.

Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by a signature log, or an attestation statement.

Initials over a typed or printed name

Initial NOT over a typed/printed name but accompanied by a signature log, or an attestation statement.

Unsigned handwritten note where other entries on the same page in the same handwriting are signed

Does NOT meet Requirements
Illegible signature NOT over a typed or printed name, NOT on letterhead and the documentation is unaccompanied by a signature log or attestation statement.   (example)

Initials NOT over a typed/printed name unaccompanied by a signature log or attestation statement.

Unsigned typed note with providers typed name

Unsigned typed note without providers typed/printed name.

Unsigned handwritten note, the only entry on the page

"Signature on file"

E. Electronic Signatures
Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.

Risk:   The Electronic Health Recod was not signed electronically 

Que/Review:  With some EMRs, it is possible that the provider did not sign off the record or log out within the prescribed time or protocol.  If a claim is billed, and the authentication was not done in a timely manner, the 3rd party may request a refund if such a medical record is submitted during an audit.   It is critically important that the electronic record have accurate time/date stamp authentication.   In addition to signature authentication, the system should ensure that the electronic record system correctly documents who is accessing and writing/authenticating the medical records/chart.  If a signature has been missed, when the provider goes back in, the time-date stamp needs to accurately reflect when the "signature" was performed.  As a best practice, it is advisable to print out the medical records/notes and review that all notes, and authentications from all parties are correctly reflected. 

Risk:  The highest degree of specificity was not assigned to the most precise ICD-10 diagnosis code

Que/Review:   At this time, Post implementation that it is imperative that the provider or coder review the notes and apply the most specific ICD-10 diagnosis code.  If the codes are input electronically by the provider, then the coder should have the option to suggest a correction, or make the appropriate corrections prior to the claim being submitted.  The ICD-10cm guidelines require us to use the most specific code as per the documentation.  However, some 3rd party payers will still pay the claim if your code is within the same "family".   However, it is of best practice to review and implement coding per the current ICD-10cm codeset guidelines regarding specificity and unspecified codes.

I.A. 9.b. “Unspecified” codes Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes  

If you do not have a "specific" diagnosis, but have signs and or symptoms, it is appropriate to report those on the claim according to the ICD-10cm guidelines

Section 1B.18. Use of Sign/Symptom/Unspecified Codes
Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.   If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. (ref ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 16/17 of 115)

Risk: Discrepancies exist between the diagnoses billed and the diagnoses in the medical record

Que/Review:  Having a different diagnosis billed on the insurance claim, not match that which was in the medical record documentation can set the stage for an audit by your 3rd party payer.   These discrepancies can happen as a simple "fumble-finger" error upon data entry.  If this is the case, then a correction of the diagnosis should be made and the claim re-processed and the medical records submitted to the carrier for verification of correct and complete documentation and coding.  

As a best practice, the coder/biller should be the ones charged with conducting auditing pre and post claims on a regular basis to avoid this issue.  If insurance claims are generated solely upon the physicians' billing via an electronic medical record interface to a patient management/billing system, an audit or review system should be in place prior to the claim being generated to avoid this type of claim error.   Many billing companies now hold or suspend claims until the charges have been reviewed.   This activity can alter or slow down your accounts receivable.  Continued ICD-10 education and audit of clinical and coded information should be a required part of the physician or hospital based billing practices.

Risk: Information is missing regarding diabetic complications, or notations if patient is type 1, type 2 or gestational diabetes.   (eg diet controlled/Medication controlled/insulin controlled)  ISSUE!

Que/Review:  In ICD-9, physicians could simply document Diabetes Mellitus – 250.00 – without specifying whether it was Type 1 or Type 2 and whether it was controlled or had complications.

The guidelines for ICD-10cm, require a much higher degree of specificity and more clearly defined clinical documentation.
As coders and providers, chronic condition documentation needs to correlate the complexity of the diagnosis status into hospital and office based care.  The element of good documentation must clearly show that the care is delivered, documented and the patient response to that care delivery and/or treatment.   If these critical pieces are not coded, the data analysis and statistics will be lost and/or skewed.  Currently ICDd10 allows us these area too review for correct coding.
·         E08  Diabetes mellitus due to underlying condition
·         E09  Drug or chemical induced diabetes mellitus
·         E10  Type 1 diabetes mellitus
·         E11  Type 2 diabetes mellitus
·         E13  Other specified diabetes mellitus

The Diabetes codes in ICD-10-CM can have up to six characters. The first three characters
represent the category, the fourth character identifies the presence of manifestations or complications, and the fifth and sixth characters identify specific types of manifestation.     

·         Physicians need to first document whether diabetes is primary or secondary to a (separate) diagnosis, or gestational diabetes.
·         Documentation should also include the body system affected, and the diabetic complications affecting that body system.
·         ICD-10 separates Type 1,  Type 2  and Gestational diabetes, along with the system that is impacted.
·         If multiple systems are impacted, each must be separately coded.
·         ICD-10 requires the provider/physician to document with Gestational Diabetes if it is "diet" controlled, "insulin" controlled or "unspecified" control.  This has been an area of concern for MD's to choose the correct code if the patients' gestational diabetes is controlled via " oral medication".  ACOG has stepped forward and acknowledged that the provider should code these type of patients as "diet" controlled.

Risk: Clinical documentation does not say if the patient's diagnoses are being "monitored, evaluated assessed or treated".

Que/Review:    Upon review, the coder or biller should review and determine if the patient's diagnoses noted in the chief complaint match and be correlated back to the care treatment plans within the chart.  If these plans are not being supported by the clinical documentation and medical necessity, this could be a risk area when billing E&M and operative procedures.  In the table below, it outlines what the "minimum" documentation requirements should be for "monitoring, evaluation, assessments and on-going treatment plans.

The Care/Treatment plan in each patient chart should reflects the patient's assessed needs and has been updated at each patient visit or hospital stay to include the status of the disease or care process.  This documentation is to include all progress (good or bad, and changing needs.)  

There is documented evidence of changes in or re-evaluation of treatment needs and/or services during periods of sudden changes in functioning or symptoms at each patient visit or hospital stay.
All treatment needs should be identified in the medical record, and documented if those diagnoses are/are not being addressed, and are prioritized based on importance/severity as determined by the physician or healthcare provider .
There is documented support that the primary care coordination and integrated care is occurring with the primary physical health care provider and any specialty health care providers and/or ancillary services requested, and provided.

In 2016 we can only guess what the payers will want to review, but these issues identified above, were targeted issues in both clinical documentation and in billing/claims from payers in 2015 as areas of interest and non-compliance.  Communication, education, awareness, and improvement will always help ensure the most complete information held in the medical and billing records.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:

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