Have You Read Your Own Documentation Lately?

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Most of today’s wound/ulcer management physicians and other qualified health care professionals (QHPs) were trained to write detailed notes about each of their patient encounters, to create and document a treatment plan, and to document their progress in meeting the treatment plan’s goals. They were taught to “paint the picture of the patient’s condition and physician’s/QHP’s work in words.” Although hand-written documentation was often hard to read, it usually provided the patient’s story and the required documentation. Then came widespread use of electronic health records (EHR). Although easier to read, wound/ulcer management use of EHRs does not always paint a clear picture of the patient’s condition and of the professional’s care.   

This month’s Consultation Corner explains why not understanding how your EHR threads together your documentation can lead to failing audits and repayments.

Scenario:

Each year this consultant receives many calls from wound/ulcer management physicians/QHPs who failed one of the Medicare, Recovery Auditor, or Office of Inspector General audits. They usually hope I can help them prove the audit findings were incorrect.    

Facts to Consider:

•    Clinical practice guidelines should always drive physician/QHP wound/ulcer management practice and should be thoroughly documented in their EHR.

•    How physicians/QHPs learned to document throughout their medical education should not change just because they are documenting via a digital device rather than with a pen.

•    Documentation required by Medicare’s National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) should always be found in their EHR.

•    Documentation should provide 1) a clear picture of the patient’s problem, results of all diagnostics, the treatment plan, procedures performed, drugs and devices ordered, and next steps; 2) clear guidance for the entire medical team, including the next site of care; and 3) all of the information in a readable format for any auditor/lawyer who requests a particular medical record.

Consultation:

When this consultant receives calls from physicians/QHPs who have just learned that they did not pass a payer’s audit, I always ask them a few important questions:

1.    What issues caused you to fail the audit?
2.    Did the information you provided to the auditor include the documentation the auditor was seeking?

Then I usually ask the physician/QHP to send me a copy of the deidentifed audit report. I also ask them to send a copy of the deidentified medical records that failed the audit to one of my recommended professional coders/auditors who understands wound/ulcer management. Once we review the audit report and the medical records, we can better assist the physician/QHP.

Sometimes we find information that was overlooked by the payer’s auditor. In those instances, we identify it so the physician/QHP can bring that information to the attention of the auditor. Unfortunately, most of the time we find obvious holes in the documentation, which caused the payer to request a repayment. Some examples are:

•    The assessment says the wound/ulcer is 100% granulated and the physician then performs a subcutaneous debridement
•    A patient has 5 wounds/ulcers, but the documentation does not track the care of each one individually
•    Orders for next visits and or procedures are missing
•    Time is not reported for services and procedures that are paid based upon time

When holes in the documentation packet are obvious, we query the physician/QHP who requested the consultation, by asking 2 questions:

1.    “Do you ever print and read your documentation of the patient encounters?”
2.    “Did you direct the collection of medical record documentation and the packet  organization and then read it before it was sent to the auditor?”

Most wound/ulcer management physicians/QHPs answer “no” to both questions.

1.    They say they focus on completing each EHR screen so they can close and sign the encounter. They do not realize their responses on different screens can provide a contradictory picture of the encounter. They also assume the different EHR screens include all the information required by NCDs, LCDs, and LCAs, which auditors use when they review documentation.
2.    They say someone in their billing/coding team prepared the documentation packet and sent it to the auditor. They do not consider that the billing and coding team does not have all the medical knowledge about each patient. Therefore, they might not include all the information that was available and might not have assembled it in an order that painted a clear picture.

This is when the real work of the consultation takes place. We educate the physician/QHP by showing her/him the holes in the documentation that was provided to the auditors. We do so by looking at the EHR screens and how that information looks in the printed medical record, and by looking at the documentation requirements of pertinent NCDs, LCDs, and LCAs and comparing their actual documentation to the requirements. We also look for required documentation components that are missing, e.g. relevant diagnosis that justifies medical necessity for work performed, treatment plan, physician/QHP orders, description of procedures performed, physician/QHP signature, and so forth. Sometimes the physicians/QHPs will say they know the missing information is actually in the medical record. We ask them to find the missing information. If they are successful, we use that as an excellent example of why they should identify the documentation components, including what order it should be assembled, that should be sent to the auditor.

During the education session, the physician/QHP often wants to blame the EHR vendor for incomplete documentation. However, the EHR vendor is only responsible for providing the digital tool to use for documentation. It is up to the physician/QHP to ensure that the correct information is documented. If the EHR software causes liability issues, the physician/QHP should work with the EHR vendor to revise the software or to create a work-around to protect her/his practice.

I usually end the consultation by recommending that the physician/QHP requests an advanced inservice from their software vendor to understand how the information  documented in each screen threads together in the final medical record of each patient encounter. If the physician/QHP finds that something needs to be refined in the software, they should request the change from the vendor. Finally, I remind the physician/QHP that she/he should practice with any requested revisions and should read the printed medical record to be sure it does not leave any holes in the documentation. Auditors cannot read what is not documented and printed.

Summary:

Physicians/QHPs should take responsibility for their own documentation and for the way it prints out as a medical record encounter. In addition, physicians/QHPs should direct the collection/assembly of the medical record components when auditors request documentation for particular patient encounters.  
        
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.