Time to audit your own medical record-keeping: Concentrate on first and second party in order to prepare for third party

April 21, 2012

Edited by Chuck Brownlow, O.D., Medical Records consultant

Much has been done recently to assist providers in their relationships with insurers, the third parties of health care. Current Procedural Terminology and the Documentation Guidelines provide step-by-step guidance for accurately choosing codes to represent the services provided. The AOA offers many valuable resources to assist members in keeping good medical records and for understanding the rules related to record-keeping. Websites for Medicare and other insurers permit doctors and staff to learn rules unique to each payer.

In spite of an abundance of information, there is still a lot of confusion among providers regarding how and when care can be provided, and how and whether the care will be paid for. 

Sometimes it may seem that the third party, the patient’s insurer, has more to say about the care provided than the first and second party, the patient and the doctor/staff. 

This confusion should provide an opportunity for a fresh look at how care is provided in your office.

It’s time to go back to basics to be sure all care is driven by the needs of the patient and by the doctor’s search for information to assist in diagnosing and managing the patient.

Some of what we hear and read seems to run counter to this basic logic. 

An insurer may pay for visual fields twice a year, yet a specific patient clearly requires a third visual field within that time period. 

An insurer may authorize payment for imaging only if the patient’s diagnosis can be found on the insurer’s list of diagnoses for which the service is paid. 

The doctor’s electronic health record might make it very easy to record a lot of data, even though the patient’s needs at a given visit are very straightforward, actually requiring very little data. 

An equipment manufacturer’s representative might explain the new instrument will “pay for itself” if used just five times each day, though the doctor may only require the information provided by the instrument once or twice per week. 

A colleague may proudly state that she/he has seen a significant increase in revenue since learning that several common diagnosis codes will assure insurance company payments for tests that used to be fairly uncommon in the doctor’s practice.

With all the conflicting information and advice swirling around today’s provider, it may be beneficial to adjust one’s focus, to simplify one’s approach. 

This is a good time to return to the roots of health care and to focus again purely on the unique needs of each patient. 

The delivery of care for every patient should be done as consistently as possible and to the extent necessary without consideration of fees to be generated, equipment to be justified, or even the rules of the patient’s insurer.

All of those considerations should be secondary or tertiary, never primary, considered after the needs of the patient are dealt with. 

With that in mind, consider the following caveats for the delivery of health care in 2012:

  • Carefully interview the patient to learn why he or she has come to the office today: the reason for the visit
  • Customize the case history to learn as much as possible about the reason, focusing on the elements of the patient’s general health history, past and present, family history, and social history that are pertinent to the needs of the patient, adjusting the reason and the components of the case history as you learn more
  • Customize the elements of the physical examination to discover diagnoses related to the patient’s reason for visit and to establish the basis for managing the patient’s conditions, including only tests that are germane to the reason for visit
  • Determine the definitive diagnosis and/or rule out diagnoses related to the day’s visit
  • Choose procedure and diagnosis codes for reporting the care to the patient and/or the patient’s insurer based purely upon the content of the record for the day

You eventually will be audited, assuming you are contracted with Medicare or other insurers, but if you commit to the caveats above, you will very likely do fine.

Your first answer to an auditor, even without looking at the specific record in question, can and should proudly be, “It will take me a moment to find and review that specific chart, but I can tell you my standard protocol for office visits. First, I carefully interview the patient to learn the reason she/he has come to me. Then I ask as many questions as necessary and possibly review an earlier case history to thoroughly inform myself regarding the needs of the patient. I customize the physical examination, doing only tests I believe will assist me in diagnosing and managing the patient’s conditions. Then I record my diagnoses and management options and explain everything to the patient, write orders for myself and my staff for future visits, tests, etc. After all of that is complete, I review the content of the record and choose the ICD and CPT codes that most closely represent what I’ve done and what I’ve found and what I plan to do for the patient as a result of my examination. Now, what was your question again?”

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