We have performed many audits/chart reviews throughout the years. Many of these reviews have been educational. However, a number of the chart reviews have been undertaken to review payer takeback requests, educational reviews performed by others, Medicare integrity actions, and legal actions. In this article, we discuss a few of the items we have discovered in reviewing medical charts as a response to reviews conducted by payers.
Mistakes by reviewers
In all the cases we have been involved with, we have yet to find a review that does not contain a significant number of mistakes. These mistakes can range from simple oversight of information included in the record to a complete misunderstanding of a payer’s own payment rules. Here is a list of common mistakes we have seen and have been able to overturn on follow-up appeal, some suggestions as to how change your documentation to prevent future payer mistakes, and a few examples of each one:
Incorrect understanding of service provided. Example 1: Chart includes findings from automated urinalysis plus red blood cell count, leukocyte count, and epithelial cell count. The chart review by payer changes code from UA automated with microscopy to UA automated without microscopy. It was clear the person reviewing the chart did not understand that the cell counts can only be obtained using microscopy. In order to prevent this misunderstanding, chart documentation can be changed to include “microscopy findings – RBCs 0-3, WBCs 5-10, etc.”
Example 2: The chart indicates “cath residual 5 mLs.” The chart is reviewed by the payer, who denies 51701 but allows 51798 (ultrasound post-void residual). To prevent misunderstanding in the future, include catheter type and size of inserted catheter in addition to “residual 5 mL.”
Evaluation and management code denied as included in services provided even with modifier –25 applied. Example 1: Chart indicates patient presents for surveillance cystoscopy. Cystoscopy findings are included and indicate new growth in bladder dome. A further indications discussion with the patient over treatment options and full course treatment ensued, lasting 20 minutes. E/M code is denied by payer as included because of a lack of a second diagnosis.
CPT and Medicare regulations clearly state a new diagnosis was not required in order to use modifier –25. Global for cystoscopy does not include subsequent treatment for findings. These cases have required pointing out that the appropriate documentation is included in the patient’s chart and providing full CPT and Medicare regulations and descriptions to the payer.
It is difficult to prevent some of these misunderstandings, even with a clear separation of procedure notes and the patient discussion. However, this denial could potentially have been avoided by using the diagnosis “bladder neoplasm of unspecified behavior” for the cystoscopy instead of “Hx of bladder cancer.”
Example 2: Chart indicates patient is present for bacillus Calmette-Guérin instillation. Chart also includes physician review of patient history, computed tomography scan and cytology, and review with patient of alternative treatments due to BCG shortage. Payer denies E/M code as included with BCG instillation.
This denial was similar to the example above. The physician spent time evaluating and recommending treatment for the disease process, clearly a separately identifiable and significant E/M service. As we have previously discussed, clear separation of a procedure note and E/M note is the best defense against denial; however, most auditors do not have a clear understanding of all medical specialties.
E/M code lowered. Many methodologies and score cards have been used by payers to judge the appropriate level of evaluation and management. Our approach in dealing with these reviews has been to first provide the payer with our scoring methodology and pocket card/wall chart system. Some payers have accepted the system, including most Medicare payers and the Office of the Inspector General. Other payers push back with scoring systems developed internally and used by their auditors.
For the payers with different scoring methodologies, we will review the chart again using the payer’s methodology, often finding the support required for the original level of service under their rules by pointing out the information included in the chart, based on a better understanding of urologic medical care.
As one would expect, the payer does get it right sometimes. For those cases, it is important to agree with the payer’s findings. This will increase your credibility for any arguments that you are making for changes in the resulting takeback. It is also important to develop an action plan to prevent future errors. It is always appropriate to review any of these records and refute the findings with clear data-based arguments. Never write a check for the requested amount.
Although we have found that many payers will offer to settle chart review takebacks that represent a significant cash return, we have found that it is important to settle these cases only after you have spent the time to truly understand and refute their findings.
Recently, we have been presented with a slightly different argument from a payer review. In this case, the payer is denying services provided in the office—including injections of LHRH, instillation of BCG, and cystoscopy—based on the claim that informed consent was not obtained.
As we are preparing to argue these denials, we have once again gone back to review the regulations for informed consent. One such resource comes from the AMA Code of Medical Ethics (https://www.ama-assn.org/delivering-care/ethics/informed-consent).
In looking for further legal guidelines for informed consent, we found a few general rules that are applied but found that these requirements are, like many rules in medicine, variable and geographic in nature. Hospitals and other entities overseen by the Joint Commission have rules that require a signed consent form (by physician and patient) that clearly indicates that the patient understands the service being provided and the risks associated with procedure to be provided that is specific for the encounter.
For the office-based setting, we did not find the same clarity or application. Specifically, we did not find any legal language or contract language that mandated that a consent form had to be in writing. We think we have a good argument with legal backing that documenting the consent statement in your record is adequate without a signed consent form. However, the audit is pending, and we do not have a clear answer for you.
Therefore, we offer the following advice for your own protection.
- First, check your state for any specific requirements for both general and informed consent. We encourage each practice to contact their medical malpractice carrier for both advice and templates that may be used for the office and hospital specific to your practice and location(s).
- From our review of records for many offices, General Consent to Treat remains a part of the new patient or “welcome to the practice” paperwork. This is a good start and should be continued.
- Based on American Medical Association guidance and review of legal firms’ opinion, you should include clear and specific informed consent in the medical record. For smaller, low-risk procedures, no separate form is required; however, it is in your best interest to have signed consent forms for any procedure in the office setting that has a moderate to high risk level.
- All consent forms and information included in the medical record should include not only a discussion of the risks, benefits, and options for treatment but a statement that indicates that the patient has acknowledged and understands these issues as it relates to the service to be provided and agrees to proceed.
Returning to our informal review of several records from few offices, we have found many groups include some standard language that will reflect a discussion of risks, benefits, and options without specific information for the procedure or drug to be provided. Additionally, we have seen a number of groups that include phrases that indicate that “all patient questions have been answered.”
The problem we see with these types of general statements is that they do not include specifics for any given procedure or drug. Many of you have secondary language that is added to the record for specific drugs and services, but these are not included in all cases. Take care to add the specifics.
Also, indicating that all patients’ questions have been answered or similar phrasing does not necessarily communicate that the patient understands and agrees to proceed with the specific treatment/service/drug prescribed. We recommend that you revisit your records, templates, and forms to include a clear indication that the procedure has been discussed in detail and the patient understands the risks, options, and benefits of treatment and wishes to proceed.
Unfortunately, we are going to recommend that this is included each time the service is provided—for example, adding the consent statement each time a patient has a BCG treatment. While understanding of risks, options, and benefits of treatment can be implied from the first time it is done throughout the patient’s care cycle for repeated treatments, most payers will not look through old records but will likely focus on specific visits. Thus, it is important to make the effort to allow each record to stand on its own.
Medical record review is inevitable in today’s world. Take care to include all relevant data when sending in record requests. It is far easier to pass a record review if the record is complete and the information is clear and easy to follow.
If you do run into issues where a payer disagrees with what you have billed based on record review, always review the records, find any additional documentation that may be needed, and finally, use data-based arguments to refute any incorrect findings. Document well, and good luck.
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.