Why Quality Documentation Matters

Posted by Nancy Clements on Nov 10, 2021 3:45:00 PM
If you work with provider claims in a medical office, then you have probably heard the phrase, “If it isn’t documented, it wasn’t done.” But a 2020 Center for Medicare and Medicaid Services (CMS) report found that more than 70 percent of claims submitted for payment were paid improperly, meaning something was incomplete or missing from the documentation submitted with a claim.

The Medicare Fee-for-Service Supplemental Improper Payment Data report* found 74.1% of the Part B improper payments were due to missing/inadequate documentation. The missing information included things like inadequate documentation to support medical necessity or missing orders. Other problems stemmed from inadequate documentation to support the services provided or other documentation required for payment of the code.

If your office receives frequent claim denials, it could trigger an audit. The False Claims Act may hold liable any person who submits a claim to the federal government that he or she knows (or should know) is false. Knowing what to look for when reviewing documentation is a proactive way to prevent improper payments and keep the practice out of legal trouble.

PMI Instructor Jan Hailey, MHL, CMC, CMIS, CMOM, CMCO, says the importance of quality documentation in the medical record cannot be overstated. It protects patient safety and coordination of care between providers and across the healthcare continuum.

Jan developed a documentation improvement program for Saint Joseph Physician Network in Mishawaka, Indiana in 2015. Now Director of Care Management with Select Health Network, she works closely with providers, management, staff, community, and payers to develop strategies on process improvement, gap closures, and patient experience. 

Jan educates coding and reimbursement staff across the country on proper documentation and claims. In her health system, she implemented a program for Hierarchical Condition Category (HCC) coding to improve risk scores. In December, she will teach a one-hour webinar, Why Quality Documentation Matters, that addresses the top root causes for inadequate documentation. Her extensive teaching experience and membership in WPS Medicare’s Provider Outreach and Advisory Group, Indiana Association for Healthcare Quality, will lend considerable knowledge and depth to this important topic.

Jan will provide more insights from the CMS report findings during a live webinar on December 16, and share fail-safe strategies that will lead to better coding and review of provider claims before they are submitted for reimbursement. If you can't attend the live session, register to get a link to the session recording within 48 hours of the live session.

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*https://www.cms.gov/files/document/2020-medicare-fee-service-supplemental-improper-payment-data.pdf 

Topics: carrier contract guidelines, medical billing, Medicare fraud, medicare compliance, patient billing