Health Care Compliance Watch : New York Health Care Compliance Lawyer & Attorney : Ilana Sable : NY Physician Representation Law

After a recent post discussing preparation and maintenance of medical records, I received several requests for further information regarding the 1995 and 1997 Documentation Guidelines for Evaluation and Management (“E/M”) Services that I briefly discussed.

The 1995 guidelines are applicable to: (a) all medical and surgical services and (b) in all settings. The 1997 guidelines, in addition to incorporating the 1995 guidelines, focus on specialists and outline each component of a typical E/M service. The following is an outline of the general principles that health care practices must adhere to when structuring medical records in accordance with the 1995 and 1997 guidelines.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

·        reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

·        assessment, clinical impression or diagnosis;

·        plan for care; and

·        date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

The CMS website has further information regarding the 1995 (pdf) and 1997 (pdf) guidelines.

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“If it isn’t documented, it hasn’t been done.”

This axiom is synonymous with the health care industry and is especially relevant when discussing audit defense. Whenever I sit down with a new audit defense client, my first three questions are always the same - “What do your medical charts and records look like? How often do you review and monitor the medical notes and records of the other physicians and ancillary medical staff in your practice? When was the last time that you conducted an internal audit to monitor your practices billing and coding, diagnostic testing and patient follow-up?” This line of questioning is almost always met with a wrinkled expression and furrowed brow, and I immediately know that I have my work cut out for me.

When discussing medical records, health care practices must guide themselves around three fundamental principles. The first is that both private carriers and federal payors review medical records using the 1995 and 1997 Documentation Guidelines for Evaluation and Management (“E/M”) Services, and that any health care practice expecting to be reimbursed for services rendered must do the same.

The second is that each state has its own state-specific laws regarding a health care practices structure, care and maintenance of its medical records. In New York, the law mandates that, among other things, health care professionals must maintain a record for each patient “which accurately reflects the evaluation and treatment of the patient,” and unless otherwise provided by law, all patient records must be retained for at least six years. Moreover, in New York, obstetrical records and records of minor patients must be retained for at least six years and until the minor patient reaches the age of 19 years.

The third is that a medical record is wholly incomplete without accurate and consistent documentation of a patient’s follow-up care. What steps were taken after the physician ordered the pricey diagnostic tests? What was the result of the extended IV Hydration Therapy?  If the follow-up care and treatment results go unanswered, questions of medical necessity, abuse and even professional misconduct can follow.

Auditors, investigators and prosecutors alike are always looking for the lapse in the story – the missing link that can be painted into an abusive, unnecessary or even unlawful method of care.  Above all, maintaining clear, consistent and well-monitored medical records is a health care practices most powerful tool in any audit defense situation.
 

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