Why Payment is Denied Based on Documentation

False Sense of Security?

We work with doctors across the country, and many of them tell us they’re not too worried about their documentation. “We’ve got that covered,” they say. “I think we’re probably fine.” And “Well we get paid!” All these thoughts can create a false sense of security. How can you really know until someone looks at your notes?

Coding statistics as well as our own practical experience tell us that their documentation is probably not anything close to fine. The HHS Office of Inspector General (OIG) reports that high percentages of chiropractic records are missing or inadequately supporting some key elements such as an evaluation, a treatment plan, and/or medical necessity. This matches what we generally find when we review documentation as a sort of “white hat” auditor. Even providers who tell us at the outset that they think their patient medical records are solid have, instead, documentation and coding errors that put their practice at risk.

These are the kinds of errors our “white hat audits” most commonly find:

Under- and over-coding Evaluation and Management (E/M) services:

Many providers are unaware of the updated guidelines required for documentation and coding of these services. Because many doctors have never even seen these guidelines, they tend to use whatever code feels right or rely on the amount of time spent without recording the time details in the patient’s note. That means some doctors will end up “guessing” a code that is too high or too low for the service performed. If you review the guidelines and make a checklist of the items required, you’ll likely be surprised at how much work you’re doing that you’re not charging for. Or you may find that you’re not documenting completely. Either way, both under- and over-coding constitute waving a red flag. Auditors target and review outliers, any doctor who falls outside normal billing patterns, more closely.

Coding and documenting incorrectly:

Doctors know the treatment they give an individual patient and therefore feel justified in how they code the service, but if their documentation doesn’t support the code, it’s a problem. Remember, as far as a third-party payer (or auditor) is concerned, if it isn’t in writing, it didn’t happen. For example, if you bill a chiropractic manipulative treatment (CMT) code for a certain level of service, but the documentation only justifies a lower number of regions treated, you’ve just waved another red flag. Note: these kinds of mistakes are most often found in post-payment audit reviews and can cost a practice thousands of dollars in repayment. This should be a reminder to ensure your daily documentation record and billing record match exactly.

Cloning records or rote justification of medical necessity:

When each chiropractic visit looks the same as the last and statements like “same as last visit” pepper the daily notes, it’s difficult for a third-party reader to ascertain the necessity of each visit. Standard guidelines dictate what must be included, and it can be easy to fall into the trap of rushing through your daily documentation. Most documentation software programs allow you to start with the notes from the last visit, and you can modify from there. The error here is that when rushed, you may be tempted to minimally modify and move on. Resist the impulse and make sure each visit and its documentation are encounter specific and reflect the patient’s progress throughout the episode of care.

These are not the only mistakes we find!

Others include easy-to-overlook mistakes like a doctor’s initials instead of a full signature, not signing the note at all, or generally illegible notes. Any of these can be a problem in an audit.

Fortunately, as with most things, admitting you may have a problem is a huge step in the right direction. Our recommendation: get proactive, and find out what’s really going on in your documentation before an outside auditor does.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.