Building a medical records compliance program for your office

June 15, 2012

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

As all physicians have known for years, Medicare and other insurers do not intend to pay for services that aren’t covered by their contracts with physicians, they don’t intend to pay for services the patients did not receive, and they don’t intend to pay for services the patient did not need. Audits by insurers and by Medicare are conducted on physicians from time to time, sometimes randomly and sometimes focused on identified or suspected departures from compliance, to determine whether physicians are complying with the national rules for patient records and any specific rules contained in the provider agreement specific to that insurer.

Professional judgment has always played a huge role in determining which patients receive which services of course, even when the physician’s judgment doesn’t square with the payer’s determination of “medical necessity” or “reasonableness and necessity.”

If such issues arise in an audit, it is up to the physician to explain why the services were provided and to demonstrate how all care was prompted by the needs of the patient at that specific visit.

In order to be confident that an office is compliant with national rules relative to patient records and the national resources for accurate choices of procedure and diagnosis codes, Current Procedural Terminology (CPT © American Medical Association) and International Classification of Diseases, 9th edition, respectively, it may be beneficial for offices to create their own internal compliance program.

The federal Office of the Inspector General (OIG) has created the framework for just such a voluntary program, built on the framework of a mandatory program that has been in force for large clinics and hospitals for more than a decade.

This Voluntary Program for Medical Records Compliance for Individual Physicians and Small Group Practices can be very helpful in guiding the protocols created for physicians and staff in small offices, ensuring compliance, and in turn, lessening concerns about the potential of future audits by Medicare or other insurers.

The OIG’s compliance program includes seven elements, permitting physicians and their staff, management, etc., to develop their own methods for fulfilling each element.

Throughout the developmental process and then through implementation of the program, offices will be conducting meetings, educational programs, establishing guidelines and protocols, doing internal audits of record-keeping, coding, billing practices, and engaging all doctors and staff in ensuring that all care meets the needs of each patient.

The seven suggested components of a medical records compliance program for individual physicians and small group practices are:

1. Conducting internal monitoring and auditing through the performance of periodic audits;
2. Implementing practice standards through the development of written standards and procedures;
3. Designating a compliance officer or contact to monitor compliance efforts and enforce practice standards;
4. Conducting appropriate training and education on practice standards and procedures;
5. Responding appropriately to detected violations through the investigation of allegations and developing a corrective action program;
6. Developing open lines of communication with the practice’s employees; and
7. Enforcing disciplinary standards through well-publicized guidelines.

The AOA provides many resources for members and their staffs who want to learn more about medical record-keeping and accurate procedure and diagnosis code selection.

If you have questions about this or other issues related to medical record-keeping, submit them to askthecodingexperts@ aoa.org.

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