When given the task of auditing a group of charts, most often the scope of the audit is well defined. For me, there are times when my
For example, the time of signature. We all know chart documentation is supposed to be done on a "timely" basis and that a note is not complete until the provider has signed off on it. This is true if the documentation is typed directly into an electronic record, is a written note or is dictation at some level. If documentation of
The next example is for time and date of the documentation. The situation is for a split shared visit. This is a visit with a Mid-level or Non-physician Practitioner (NPP) in a hospital inpatient, hospital outpatient or emergency department. The documentation of both the NPP and the physician when combined must support the level of E&M service billed with both of them documenting a "substantive" portion of the history, exam or medical decision making (IOM Chapter 12: 30.6.13). Documentation of the work of the physician and their signature must be on the same day as the NPP note. That date is the DOS that should be billed. If the physician does not make an acceptable entry in the record for a DOS then the work of the NPP is the only documentation considered for billing. This code for the NPP's level of service and the date of service that the NPP saw the patient, are the items that are billed. I see this as a problem most often when the patient comes in late in the evening. The NPP does the admission for the patient and then the attending comes to see the patient. It is when these two services are not on the same date that the problem occurs with the physician submitting the admit date as the DOS for service and combining their note with the NPP's for a level of service. Both of which are incorrect actions.
The last example for time (and date) of the attending physician's note occurs when working with PATH services (Physicians at Teaching Hospitals). Again, we look to CMS/Medicare for comment when a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until the next calendar day. The teaching physician's bill must reflect the date of service he saw the patient and his personal work of obtaining a history, performing a physical, and participating in medical decision-making (IOM Chapter 12:100.1.1.A). Many teaching physicians will, mistakenly, submit a bill for the date the patient was admitted rather than the date THEY saw the patient. Using an admission code on the date following the actual admit date to the hospital, can cause edit problems. So your physician needs to let the billing department know of the discrepancy so they can be prepared to appeal any rejections.
Taking a minute to look at the timing of a provider's documentation. This quick check on the documentation of
This Week's Audit Tip Written By:
Jill Young, CPC, CEDC, CIMC
Jill is the owner of Young Medical Consulting, LLC based in Michigan.
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