How Auditors Want You To Manage E/M Documentation

You’ve read about the risks of improper E/M coding, you’ve been warned about unbundling, and and how to tackle common auditing challenges but you might be surprised to learn that all risks aren’t a result of inaccurate coding. Insufficient documentation, one of the most common problems that results in improper payments, is often overlooked despite substantial economic consequences like improper payments or refunds.

Improper Documentation Results in Improper Payments

In order to protect your organization from financial loss, it’s crucial to know the risks related to poor documentation. “Insufficient documentation,” according to the Centers for Medicare and Medicaid Services, “can be to blame for a large number of improper payments.” Sloppy handwriting, missing patient information, or a missing date are among the most common documentation errors.

The number one cause of improper payments is a missing signature. Payers and CMS require legible documentation, and sufficient documentation for payout. Without a valid handwritten or electronic signature, services can’t be authenticated. Even with perfect coding, if the document lacks a legible signature, the entire note will be disregarded.

Missing Documentation Can Result In Full Refunds

There are a number of reasons why medical records go missing: Staff members, don’t realize the importance of the records, or the office staff was too busy. It’s a difficult and frustrating situation for both auditors and practitioners. It’s also a particularly expensive mistake because if the chart note isn’t present, the entire service must be refunded.

Lowering Documentation Risks 

You can save your organization from significant economic losses by simply keeping an eye on your practice’s documentation. Correct coding is vital, but if charts are missing, or signatures are impossible to read or absent altogether, the audit outcome might lead to unwanted consequences.

For more information on how to overcome insufficient documentation and make record access a priority, download our short ebrief, "What Auditors Wish You Knew", for all the details: