Document, Document, Document

Documentation is vital to providing good, consistent patient care, but it's also vital if you expect to be reimbursed for that care—especially if the care is provided to Medicare patients.

APA's Managed Care Help Line has received calls for assistance from more than 15 doctors who provide inpatient care in Florida. The Florida Medicare carrier, First Coast Service Options, apparently put all inpatient psychiatric care in certain areas on 100 percent prepayment review starting last summer because of an alleged “culture of fraud.” That means that every time a claim was submitted to First Coast, instead of the psychiatrist receiving payment, he or she received a request for the documentation of the care that the claim represented. After the documentation was reviewed, the claim was either paid, down-coded, or rejected. In some cases claims were accepted for several days of care but denied for intervening days (that is, the carrier paid for care provided on day one and day four, but denied payment for care provided on days two and three), because the documentation was deemed inadequate.

APA's Office of Health Care Systems and Financing (OHSF) contacted the carrier's medical director and was able to get most of the psychiatrists who contacted OHSF taken off the prepayment review so that in the future claims should be paid as filed.

Unfortunately, even though the Medicare carrier has acknowledged that the psychiatrists whose claims were reviewed should not have been placed on prepayment review because there was no reason to suspect they were engaging in inappropriate billing, the rejected claims will be paid only if they are appealed, a process that could take months. (Note: OHSF recommends appealing denied claims. The majority of appeals are won if the physician is willing to pursue them as far as the Administrative Law Judge level.)

In the case of the rejected inpatient claims, failure to provide complete documentation of care provided each day created this problem. It may seem that documenting treatment that is primarily a duplication of what was done the day before is just a waste of valuable time, but if you expect to pass an audit, that's exactly what you need to do. (OHSF also recommends that psychiatrists who provide inpatient care keep a copy of all their documentation. Sometimes claims are denied because the facility is unable to produce the doctor's documentation.)

Whether you provide inpatient or outpatient care, the trick is to find a documentation method that is efficient. Using a template that requires you to fill in the blanks is a good way of ensuring you don't miss anything important.

Medicare carriers generally provide their documentation requirements in the Local Coverage Determination (LCD) policies they publish for the procedures they cover. The LCDs can be accessed at the carrier's Web site, where other valuable Medicare information can be found as well.

Medicare's documentation guidelines for evaluation and management (E/M) codes are posted on the Web site of the Centers for Medicare and Medicaid Services<www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf>. For psychiatrists, the most important section in the E/M guidelines may be the chart on single organ system examinations.

Over the years, the coding experts at APA have found that documentation for a psychiatric evaluation will almost always meet Medicare carriers' requirements if it includes the following elements: date of service, chief complaint, referral source, history of present illness, psychiatric history, medical history, social and family history, comprehensive mental status examination, treatment plan formulation/prognosis, assessment of the patient's ability to adhere to the treatment plan, multiaxial diagnoses, and a legible signature. For psychotherapy codes, documentation will almost always meet requirements if it includes date of service, time spent for the encounter face-to-face, type of therapeutic intervention (that is, insight oriented, supportive, behavior modification, interactive), target symptoms, progress toward achievement of treatment goals, E/M services provided if code is for psychotherapy with E/M, diagnoses, and a legible signature. ▪