Chart Review and Education

Gina Hobert, Healthcare Consulting Senior Manager
March 2016

When was the last time your facility/organization reviewed bills and medical records for compliance with applicable coding, billing and documentation changes? The Department of Health and Human Services’ OIG Compliance Program for Individual and Small Group Physician Practices recommends education and training to providers, followed by a medical record review on an annual basis.

A few potential risk areas identified by the OIG that affect providers include:

  1. Billing and coding
    1. billing for items or services not rendered or provided
    2. double billing
    3. billing for non-covered services
    4. over and/or under coding
  2. Reasonable and necessary services
    1. ordering only tests, including screening ones, appropriate for the treatment of the patient
    2. ordered services meet the Medicare definition of reasonable and necessary
  3. Documentation
    1. A complete and legible medical record
    2. Rationale for ordering diagnostic and other ancillary services
    3. Proper use of CPT and ICD-10 codes for claim submission that are also supported by appropriate documentation

Proper coding is essential for medical billing compliance and can dramatically impact reimbursement. Coding reviews are designed to provide a summary of data quality, documentation, accuracy and assignment. At the conclusion of a review, findings, recommendations and issues should be communicated. It should be understood that the focus is patient care and the medical record, first and foremost, is a patient care tool. The medical record/encounter, however, must also be a coding, billing and compliance tool. Any education and discussion should reflect this understanding and concentrate on coding documentation requirements and methods which practitioners can employ to document what they do and how that documentation translates into code selection.

For more information regarding BNN’s approach to external chart reviews, please feel free to contact a member of our revenue management team at 1.800.244.7444.

Disclaimer of Liability: This publication is intended to provide general information to our clients and friends. It does not constitute accounting, tax, or legal advice; nor is it intended to convey a thorough treatment of the subject matter.