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Guidelines from CMS to ensure that patient’s health record contains quality documentation


15th July 2016

Guidelines have been released by The Centers for Medicare & Medicaid Services (CMS) to ensure that every patient’s health record contains quality documentation. The general principles which have been laid down by CMS for medical record documentation with regards to reporting of medical and surgical services for Medicare payment are as given below:

  • • Medical records should be complete and legible
  • • Documentation of each patient encounter should include:
    • Reason for encounter and relevant history
    • Physical examination findings and prior diagnostic test results
    • Assessment, clinical impression, and diagnosis
    • Plan for care
    • Date and legible identity of observer
    • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
  • • Past and present diagnoses should be accessible for treating and/or consulting physician
  • • Appropriate health risk factors should be identified
  • • Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented
  • • CPT® and ICD-10-CM codes reported on health insurance claim form should be supported by documentation in the medical record.

According to CMS, Medical records should satisfy the following criteria to be considered as complete and legible

  • • all medical records, including progress notes and treatment plan, should have the date of service, and should be promptly signed and dated by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished.
  • • Many claim denials occur because a provider/supplier did not submit sufficient documentation to support the service/supply billed (fails to demonstrate it is reasonable and medically necessary).
  • • For every service billed, a provider must indicate the specific sign, symptom, or patient complaint necessitating the service.

New rules finalized by CMS to give employers and providers better access to data

The Centers for Medicare & Medicaid Services (CMS) has finalized new rules allowing the sharing of analyses and data between providers, employers, and others. The new rules will help in more informed decisions about care delivery and quality improvement.

The rules seek to enhance the current qualified entity program to allow innovative use of Medicare data for non-public quality improvement and care delivery efforts while ensuring the privacy and security of beneficiary information. The rules will help to abide by the Affordable Care Act’s Qualified Entity Program and are required by the Medicare Access and CHIP Reauthorization Act (MACRA). The new rules will allow organizations approved as qualified entities to confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups who can use the data to support improved care.

Qualified entities can also provide or sell claims data to providers and suppliers such as doctors, nurses, and skilled nursing facilities. The rule includes strict privacy and security requirements for all entities receiving patient identifiable and scrubbed analyses or data. If entities receive identifiable data, they must use the stringent requirements of HIPAA Privacy and Security Rules.

Minimal impact of ICD-10 conversion on hospital denial rates

The United States’ healthcare industry transitioned to ICD-10, increasing the number of diagnostic codes from 13,000 to 68,000 after three delays and much industry opposition. The transition was expected to disrupt providers’ finances. However, new data from the report shows the conversion minimally impacted cash collections, initial denial rates and days in accounts receivable, according to a report from public accounting, consulting and technology firm Crowe Horwath.

Crowe Revenue Cycle Analytics compiles and organizes a daily feed of transactional-level data from the patient accounting systems of nearly 600 hospitals. These reports outline findings based on an assessment of key performance indicators related to billing and coding, accounts receivable and denials.

Findings of the report are as detailed below:

  • • On average, there was minimal impact on cash collections, initial denial rates and days in accounts receivable due to the ICD-10 conversion; however, there were delays in inpatient billing and coding. This resulted in a 10.1 percent increase in inpatient discharge and not final billed days from October through December 2015, compared to the same period in 2014.
  • • There was a temporary increase in denial claim adjustment reason code 11, indicating the diagnosis is inconsistent with the procedure for a small number of hospitals. As a result this denial reason code increased from October through December 2015.
  • • There was increase in cash leakage from denials with respect to initial denial rates which ranged from 3.1 percent to 7.7 percent of gross patient services revenue, including some greater than 11 percent.
  • • In most cases, calculated denials realization gap indicates more cash leakage is occurring than the final denial write-offs indicate. According to the report, this typically occurs due to using contractual and administrative adjustment codes that are used instead of the correct final denial write-off codes in cases where collections departments are unable to successfully resolve denied accounts.

Healthcare fraud claim settled by University of Missouri

The University of Missouri has agreed to pay the federal government $2.2 million to settle a claim that their health care program physicians committed fraud. The program is part of the University of Missouri Health System. It has made a five-year corporate integrity agreement with the Office of Inspector General for the U.S. Department of Health and Human Services.

The program was accused of violating the False Claims Act by submitting claims for radiology services to federal programs such as Medicare and Medicaid, and maintaining that radiology images had been reviewed by physicians. Federal health care programs only pay when a physician is involved with the review. A federal investigation had found that physicians had not reviewed the radiology images. Federal officials claim the reviews were conducted by resident physicians.

The university is also repaying the federal government about $3 million for unrelated billing issues discovered during the radiology review investigation. That payment is related to a series of overpayments from 2001 to 2013, in which the health system did not properly bill the government for two specific tests and treatments.

The Federal False Claims Act violated by Louisville Based MD2U holding company

MD2U Holding Company, including its related companies and individually named owners has agreed that they violated the federal False Claims Act by knowingly submitting false medical claims to Medicare and other government health care programs, altering records to support false claims, and providing services that were medically unnecessary.

Due to violation the company has agreed to pay millions to resolve the government lawsuit filed against them. MD2U utilized an electronic medical records (EMR) system that permitted to easily electronically cut copy and paste medical notes from prior visits. The ability to migrate notes from visits that occurred weeks, months, or even years prior to the current patient encounter created the illusion that MD2U were performing a significant amount of work during their patient encounters when, in fact, they were not.

If the documentation was deficient to bill the highest level code, MD2U would direct the concern department to go back and change the medical record after the encounter had occurred to falsely show that more work was performed during the visit in order to support the highest level billing.


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