By Rose T. Dunn, MBA, RHIA, CPA, FACHE

Good documentation is the best defense against a negative audit outcome.

We often find ourselves grousing about Dr. X who never documents something or Dr. Y who notoriously doesn’t enter their notes until the end of the week. Have you chatted with your peers in other practices to see how they have addressed similar bad habits?

What about the provider who treats patients with multiple conditions but only documents one condition? Have you researched their public profiles and those peers in the same specialties? This is an interesting way to give the provider feedback on how their profile compares to others in the same specialty and in the same community.

Visit this site where you can show the provider how their data compares to their peers.

How often is formal education provided for your clinicians and physicians on best documentation practices? And how often are coding and documentation audits conducted and reviewed individually with the providers? Providers appreciate data—that’s how they work. We all like to know how we’re doing.

In summary, the key focus items for your HCC audit are:

1. Is the diagnosis on the claim supported by the clinical documentation? Does the encounter show that the condition was truly addressed and not just copied forward from another encounter?

2. Were all the diagnoses addressed in the encounter placed on the claim, regardless of whether the diagnoses trigger an HCC?

3. Have there been any rejections/denials of diagnoses from the Medicare Advantage or ACA plan? If so, was the denial appealed? If the denial was not successful, is the diagnosis that was denied by the plan submitted by the plan to CMS? If so, alert CMS.

4. Are your records meeting the other documentation requirements? I.e., are there 2 identifiers on every page, are the credentials for the provider appearing in the record, are the encounters dated, etc.?

By focusing your attention on quality documentation and assertive denial defense, you ensure the accuracy of both your data and your reimbursement.