Medicare recently started denying an increased number of claims because documentation submitted for diagnostic tests does not include signed test orders or evidence of intent (MD progress notes listing tests needed) and evidence of medical necessity (description of clinical conditions and treatment showing the need for the testing).
Most of us who have gone through the implementation of a EMR realize that electronic medical records do not always “tell the story” of a visit in the way that paper records used to. Encounters are documented without the glue that allows an auditor to understand what went on during the visit. Here are three ways to make sure that your documentation meets requirement for Medicare and other payers.
Establish medical necessity: Make sure the test is attached to the right diagnosis
Some providers attach all diagnoses assigned to a visit to any/every test ordered and performed. This is incorrect. All diagnoses can be attached to the Evaluation & Management (E/M) code, since all were addressed during the visit. Don’t list any diagnoses from previous visits that were not addressed at the current visit unless you note their impact on your decisions for care at the current visit.
Remember that screening tests and diagnostic tests are two different things. A screening test is ordered when you are looking for something with no provocation. A diagnostic test is ordered when there is a sign or symptom that prompts the provider to look for the cause.
Reveal your decision making process in the record
Examples of this might look like these:
“Need add’l tests to est. xxxxxx. Plan to…”
“Return in 3 wks and repeat test to establish…”
“DM worsening – will….”
“Consider d/c xxxxxx medication if fatigue persists.”
“Hypothyroidism vs. anemia?”
“Fatigue most likely sec. to HTN meds – r/o electrolyte abn.”
“DM stable, continue current regimen, recheck in 3 months.:
Don’t forget the signatures!
A signature log can be as simple as entries on a document. Here’s one example:
Provider Name (printed): ______________________
Full signature (written by provider): ______________
Initials (written by provider): ___________________
They’re simple paperwork hacks with the power to save you and your staff hours. Got some of your own? Let us all know here, or tweet them to @zocdoc; we’ll compile and share our favorites.
Mary Pat Whaley (Twitter: @Mary_Pat_Whaley) is the President and Co-Founder of Manage My Practice. She is widely quoted in national practice management magazines including Medical Economics, Physicians Practice, the Journal of Medical Practice Management, and Physicians Digest. She is also a Healthcare LinkedIn Thought Leader, and a member of the Advisory Board to the Mayo Clinic Center for Social Media, where she is currently creating three Social Media Residency curriculum courses.