Medical Record Documentation … will your’s survive a RAC audit?

Medical Record Documentation RAC Audit

Does your medical record documentation support the codes you’re using?  And why should you care?  Well, one reason is because the Centers for Medicare and Medicaid (CMS) has just announced new efforts to analyze claims submitted for payment by Medicare, utilizing new “cutting edge methods” to identify fraud and abuse.

CMS is attempting to prevent payment of medical claims that may be fraudulent, vs. chasing providers for refunds of claims already paid.  To accomplish this, CMS will use a risk-scoring methodology to identify providers who may then be the target of anti-fraud agencies such as Recovery Audit Contractors (RACs).


Medical record documentation, risk categories, and claim submission patterns

So how will this work its way down to individual providers?  CMS is already assigning providers to risk categories based on past investigations.  For instance, physicians may be in the lowest risk category, while Home Health and DME providers in the highest.  But it doesn’t matter what category you are in if CMS detects a questionable pattern of claims submission, such as a skewed profile of the use of Evaluation & Management (E&M) CPT codes, or submission of a volume of claims that could not be humanly accomplished in a day or a week.


Fraudulent medical claims most often lead to exclusion and prosecution … not settlements

And the “hammer” will be heavy.  It is interesting to note that each week several providers are prosecuted or sentenced, or excluded from Medicare, for fraudulent claims activities.  Yet the number of corporate integrity agreements (CIA) the HHS Office of Inspector General enters into each month is only a fraction of the number of providers prosecuted or excluded.  This seems to indicate CMS and the Department of Justice can find enough evidence to impose harsher penalties, vs. allowing providers to continue in the Medicare program under formal compliance arrangements.


So how does all this relate to medical record documentation?

For physicians using E&M codes for many of their services, the one of the keys to defending yourself from post-audit give-backs, let alone getting into a CIA, getting excluded from Medicare or prosecuted, is to make sure your medical records documentation meets the CMS requirements for this documentation.

The standards for this medical record documentation are fairly clear.  Many physicians do an excellent job of documenting their patients’ conditions and their plan for treatment – in their heads.  The challenge is to get it on paper or into your EHR.  That’s the only place it matters when you get audited.

And it doesn’t matter that your documentation is no worse than what you see other physicians doing in their office or hospital notes.  CMS does not grade on the curve

To learn more about the best practices in E&M documentation and coding take a moment to flip through our presentation on medical documentation and Risk-Based Coding.  CMS is taking preventive steps to cut down on fraud and abuse.  Implement your own prevention program by making sure your medical records documentation is where it needs to be.  What are you waiting for?

When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.