Posted by: notdeaddinosaur | January 9, 2012

Why Medical Documentation is Like Speeding

Much — oh, so much — has been written about how doctors document the medical care we provide. As I sit there furiously scribbling in a chart typing on the keyboard, patients sometimes ask if I have to write all of that in order to get paid.

Well, no; but, yes. The dirty little secret about the relationship between documentation and payment is similar to the concept of the speed limit.

Medicare and other insurance companies do not require that I submit copies of my documentation along with a claim in order to be paid for regular, everyday kinds of services. It’s not hard to see why. They’d quickly become swamped with — and paralyzed by — mountains of paper and/or bytes of data that, for the most part, are completely routine. I’m told that some surgical procedures and perhaps some other specialists do indeed need to routinely include such documentation, but I do not. I’ve gotten requests for documentation for some high-level services (level 5 office visits, which occur rarely), and auto accident claims generally require  office notes to be included. But Medicare generally just processes the claim and sends off the check. Same thing with most of the other insurance companies.

Is it just the honor system that compels me to maintain appropriate documentation? Not exactly. My agreement with Medicare and my contracts with insurance companies do indeed state that I agree to do so, but beyond that I’m pretty much on my own. They do have the right to come in and check up on me after the fact (ie, after they’ve already paid me), so all it really comes down to is the risk of getting caught. All risks can be calculated. In this case, I present the analogy of obeying the speed limit and other traffic laws to medical documentation.

The major variables involved with driving are time and place. I’ve run red lights at three in the morning because I’m exhausted, dying to get home, and just don’t want to wait the two minutes for the damn light to change, and there’s no other car as far as they eye can see. I’ve never gotten caught. On the other hand, I know of a stretch of road not far from my house that’s crawling with police cars and speed traps, especially on Sunday mornings. Zip along at 80 mph and there’s a better than even chance of getting pulled over for a close encounter of the cop kind. Similarly, everyone is familiar with highways where traveling the posted speed limit makes you an actual road hazard as everyone else zips by you five, ten, twenty miles per hour faster.

How do you go about calculating the risks of getting caught fudging medical documentation? Let’s see:

How many people of your acquaintance have ever received a speeding ticket? It’s not rare.

How many doctors do you know who have been audited by Medicare?

Oh, it happens. In fact, President Obama has recently called for intensification of audit attempts to detect theft and fraud. There are all kinds of scary stories out there about bounty-hunting companies incentivized to produce by promises of percentages paid to them. For the most part, though, they’re after the big fish: hospitals, large groups, phantom DME suppliers. Little fish like me, solo docs with less than $20,000 in Medicare billings a year, aren’t worth their trouble.

As a practical matter, while my chances of needing to show those frantic tap-tap-tappings in order to get paid (more likely to keep money I’ve already been paid) are somewhere between slim and none. Don’t get me wrong: my documentation is flawless. Not like certain specialists with their new EMRs who use templates to document out their asses, laughing all the way to the bank. Because if I do get audited and my documentation is lacking, I could potentially end up in jail, though more likely just bankrupt. Either way, I don’t mean to imply that it’s something to fool around with.

The major purpose of medical documentation is medical care. That’s the real reason I keep immaculate records; to reflect the excellence of my care. Protection against litigation is a distant second, with payment issues behind that. I write all my records as if they are going to be pored over by a lawyer, even though it’s very unlikely. Medicare and other payers shouldn’t have any trouble finding what they need, at least according to assorted reviewers who have perused them over the years.

It’s also a little like trying to cheat on your taxes. The chances of getting caught may be small, but the consequences are significant.

So no, I don’t need to write all that to get paid, any more than you follow the speed limit to avoid getting a ticket. You drive safely to be safe. And I write what I need to take care of you.

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Responses

  1. Documentation is a hassle. The old days supposedly in the 1970s documentation could be 1-2 sentences per visit. Once the insurance companies, Medicare, and litigation risks came into play, documentation now is most of the visit.

    I have noticed that the commercial EMR users have 2 pages ROS templates asking every question imaginable. I dread records from docs who have left the area and have EMR systems. I get a 1-2 inch stack of notes for the last 2 years or a CD with 600 pages of office notes for only 2-3 years worth of visits. Most of the visits could be summarized in 1-2 sentences.
    As a side note, I am a solo doc with 40-50% Medicare. The Medicare PPO contractors request 2 years worth of office notes annually, meaning they often request the same notes twice for billing and coding audits. The only feedback I have received is that my visits are coded correctly and that sometimes I could have coded to a higher level of care.
    Finally, every work comp and every MVA visit receives records requests from the insurance companies and lawyers. Durable medical goods and diabetic supply companies also request office notes. It is a lot of paperwork for level 2-4 visits that goes uncompensated.


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