Documentation of a patient encounter is just as important to the entire process of patient care as face-to-face interactions with the patient, quality of delivered services, management of patient outcomes, and selection of CPT (Current Procedural Terminology©, American Medical Association) and diagnosis codes. The documentation of each encounter expedites patient care of the individual in subsequent visits by revealing historical accounts and diagnostic findings that may impact decision-making, patient management, and monitoring of a patient's status over time.
Documentation also provides a means for continuity of care, even when there is no continuity of providers. A detailed and accurate recording of an encounter reduces the challenges of claims processing and may serve as a legal document to verify that services were delivered in a manner beneficial to the patient.
The world of health care has grown tremendously in both range of services and cost. As such, it has drawn increasing scrutiny by government and commercial third-party payers to ensure that appropriate services are delivered and that payments are appropriate and justifiable. The expansion and cost of health care also have captured the attention of the legal world with malpractice claims receiving very impressive punitive damage awards.
There is a saying among those who deal with Medicare, "If it wasn't documented, it didn't happen." This saying has nearly universal application to all third-party payers when they exercise their right to come to your office and inspect the records of patients under their coverage oversight.
The principles of documentation were originally developed for physicians who use the Evaluation and Management (office visit) type procedure codes, but have been generally applied in their basic elements to all aspects of health care (CMS Documentation Guidelines, 1997). They are rather straightforward but do not allow "cutting corners" and must be appropriate. The documentation justifies why the patient was seen, what was done, what was found, and what was recommended. Together these components of documentation justify and support the respective selections for procedure and diagnosis codes.
The Elements of Documentation
A minimum of six elements must be included to comprise appropriate documentation-the signature, service date, and four others:
- History. The history section of a report must document why the patient is present. This should include the chief complaints, signs, and symptoms; pertinent medical, social, and family history; and the referral's origin. The report's history section should be sufficient to justify the medical necessity of the patient visit and the procedures that were performed.
- Procedures performed. This portion of the report should document the procedures executed and the diagnostic test results for each procedure. The detail should be sufficient to include indications of outcome reliability, special circumstances, and noteworthy information that may influence interpretation of the test results.
- Clinical assessment. This section is an interpretation of the findings. Sufficient detail and discussion should be included such that the unfamiliar reader may understand not only what was found, but also why it is important to the overall well-being of the patient.
- Recommendations. This section should be a logical flow from the previous three sections and should contain specific recommendations for follow-up, referral, discharge, or a plan of care. The recommendations are influenced jointly by the history, the diagnostic procedures performed, and the interpretation or clinical assessment.
Taken together, the combination of all four sections of the report should permit an unfamiliar reader to understand why the patient was present, why the audiologist performed the selected procedures, the significance of what was found, and the logical recommendations derived from the preceding three sections. In addition to the evaluation, all recommendations must be based on the principle of medical necessity.
The requirements for speech-language pathologists are very similar but have been codified into the federal regulations governing all aspects of Medicare. The requirements, found in the Code of Federal Regulations (42 CFR 485.721), are as follows:
In the event of an audit, all documentation, especially that which is handwritten, must be legible and clearly readable. Documentation that is present but illegible or unreadable is not acceptable and will be counted as incomplete or inappropriate documentation.
There will be occasions when evidence exists that a service was provided but the corresponding documentation is not present or complete. Examples of such instances include sign-in sheets, processed vouchers, and credit card receipts. The elements of evidence cannot substitute for the appropriate written documentation that must be in the patient's record. Auditors and reviewers are not allowed to accept ancillary evidence of the patient's presence as confirmation that a service was provided (Medicare Transmittal No. 86, HCFA, 2001). The primary interest is not whether the patient was merely present, but the appropriateness of the activities within the session, the response of the patient to intervention, and evidence that the patient is making appropriate progress over time.
Errors and Revisions
If errors are found in the chart notes or the formal report, do not remove and destroy the report if it has been finalized and placed in the patient's chart. If a single word error is discovered, generally a pen-and-ink correction is acceptable. Draw a single line through the incorrect word, write the correct word, and place the initials of the person making the correction adjacent to the sentence. If pieces of information are incorrect or information is discovered that changes the interpretation and recommendations, the clinician should prepare an addendum report that bears a preparation date and place it in the patient's chart. The addendum must reference the date of service and specify which elements of the previous report are incorrect and what the correct information should be. It is extremely important that the original report is not destroyed, rewritten, or replaced. Obviously, the moral of the story is to "get it right" the first time. However, errors will occur. When they do, acknowledge and correct them in a manner that does not suggest malicious intent or a cover-up [HCFA, 2001; and 42 CFR 482.24(c)].
There also may be occasions when the patient requests changes or amendments to the record. Under the Health Insurance Portability and Accountability Act (HIPAA), patients do not automatically have the right to remove or change information in their medical charts. Patients must petition health care providers in writing with regard to the desired changes and provide an explanation for the rationale for the changes. The audiologist has the right to accept the request if incorrect information is in the record or deny the request if the documentation is accurate and complete (45 CFR 164.126).
Either decision, however, will require independent documentation in the patient's chart and should include the specifics of the patient's request, the rationale on the part of the patient, whether you as the health care provider accepted or rejected the patient's request, and your rationale. A written denial must be forwarded to the patient clearly explaining the reason for the denial. Conversely, if the request for amendment is accepted, the patient and any "Business Associates" as defined by HIPAA who may have received the original documentation (45 CFR 164.126) must be notified.
Numerous facilities employ professional coders whose primary function is to examine the documentation, lab results, and diagnostic test outcomes and from that select the most appropriate codes for billing purposes. Many audiologists and SLPs are not aware of the codes that were selected or the rationale behind the selections. We believe that professional coders should not have the final authority on code selection as a matter of medico-legal propriety. In the event of an audit or review, the licensed provider is held responsible for the appropriateness of all claims submitted to Medicare and other third-party payers (42 CFR 1001.901).
Because of this responsibility, the provider should be the primary individual to select both the procedure and diagnosis codes for billing, or at a minimum, should review the code selection by professional coders in order to ensure accuracy in claims submission. If the selected codes are not appropriate or do not agree with the documentation, the provider must have the authority to override the original code selection and correct the claims form before submission.
For helpful information about coding for audiology and speech-language pathology services, visit ASHA's Coding for Reimbursement Web page.
Students and Documentation
Students involved in the documentation process need diligent supervision. First, students-including fourth-year AuD students-are learning how to write an accurate report. Sometimes the grammar is so complex-in an attempt to be "proper"-that no one understands what the student is saying. On other occasions, many details are left out that are important for the clinical assessment, determination, and generation of recommendations.
Both Medicare and Medicaid require the licensed, supervising audiologist to have contact with the patient during the evaluation. The Medicare Claims Processing Manual (Chapter 5, Section 110.10.1.A, www.cms.hhs.gov) addresses the participation of students in the evaluation process and places significant restrictions upon their ability to function independently. In a clarification letter to ASHA dated Nov. 9, 2001, Terrence Kay, a senior Medicare administrator, affirmed that those restrictions extend to audiology students.
For Medicare patients, the licensed, supervising audiologist must be in the room with the student during the evaluation and must actively participate in all aspects of patient care. All billing must be prepared by the licensed audiologist, not the student. In like manner, the preparation of the report falls entirely to the licensed audiologist to ensure that the requirements of documentation are met and the report accurately conveys the justification of medical necessity, description of activities, clinical assessment, and recommendations. Although Medicaid also requires contact with the patient and involvement with the evaluation process on the part of the licensed, supervising audiologist, the requirements are not as strict as for Medicare (Federal Register 2004: 69, No. 104).
As a reminder, the report is not only useful for billing-it is also a legal document that may be extremely important at some future date.