Looking Over Your Shoulder in Healthcare: Chart Audits

Part 2

Carolyn Buppert, NP, JD


December 08, 2011

In This Article

Payers Are Looking at Documentation

Medicare, Medicaid, and commercial insurers and health plans are looking at the following aspects of documentation:

  • Whether a hospital medical record supports the necessity of the hospitalization;

  • Whether the progress note justifies the billed procedure code for a physician service;

  • Whether the note and the clinician's signature are legible;

  • Whether time spent face to face with the patient is recorded when the clinician is basing choice of CPT code on time spent counseling or coordinating the patient's care; and

  • Whether incident-to or shared visit rules are met.

Deficiencies found on audit can lead to denial of payment for the hospital stay and for physician or NP visits.

Medical Necessity, Level of Care, and Properly Ordered Services

Medicare and other payers deny claims for payment when documentation to support a hospitalization or physician service is insufficient. When a payer audits a facility, sloppy documentation can lead to denials of payment and inspire auditors to look for other indications of carelessness. According to instructive Web-based seminars offered by one of the Medicare Administrative Contractors, auditors have identified these errors in documentation:[1]

Errors in documentation of physician services (Part B claims):

  • Coding nearly every encounter as equal in complexity;

  • No documentation of reasons for lab tests or ancillary services;

  • Inadequate documentation to back up coding;

  • Coding for a service that was never performed;

  • Duplication of coding of a single service that was performed;

  • Unbundling services when a single code is available;

  • Incorrect date(s) of service submitted on claim form; and

  • Incorrect place of service based upon service billed.

Errors in documentation to support hospital services (Part A claims):

  • Inpatient stays were determined not to be medically reasonable and necessary on the basis of submitted documentation. Documentation justified only that the beneficiary's condition could have been treated on outpatient/observation basis; and

  • Lack of physician order for a diagnostic test, as well as lack of justification of the clinical necessity of the test.

The consequence of such errors is denial of payment to a hospital for a patient's stay or a demand for repayment of payments made for physician services. For example, a commercial insurer audited the office visit notes in a neurologist's practice and demanded repayment of approximately $25,000 because the progress notes did not support the level of services claimed during the period that was audited. The neurologist was surprised and upset, because she knew that her patients' cases were complicated and that she spent a significant amount of time with each patient. However, a review of the physician's notes and those of the NP with whom she practiced showed that CPT 99215 was often used, yet the notes did not show sufficient history, examination, or medical decision-making to justify that code. Neither the physician nor the NP had participated in coding classes. Because these clinicians had never been audited, they assumed what they were doing was correct.


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