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Building an Effective Rheumatology Compliance Plan


Kansas City, MO—At the 12th annual National Organization of Rheumatology Managers conference, held September 14-16, 2017, practice managers, physician managers, and other healthcare administrators gathered to network with their peers and attend educational sessions on the future of rheumatology management in the age of value-driven healthcare.

During her keynote presentation, Shannon O. DeConda, CPC, CPMA, CEMC, CEMA, CMSCS, Partner, DoctorsManagement, LLC, Knoxville, TN, and President and Founder, National Alliance of Medical Auditing Specialists, discussed how careful documentation can be used to successfully defend providers, practices, and claims, and the importance of understanding regulatory compliance issues, especially those pertaining to medical necessity.

The Importance of Proper Documentation

Kicking off the discussion, Ms DeConda underlined the importance of properly documenting patient–provider encounters, which is necessary to confirm medical necessity for all services that are billed (Figure). The increased use of electronic medical records (EMRs) will continue to place even more demands on practices to provide accurate and thorough documentation, she noted.

“Documentation is not supposed to be the purpose of treating patients, but we have moved into a healthcare industry that has forced providers to move beyond patient management and into becoming documentation specialists,” said Ms DeConda.

Documenting patient–provider encounters

An assessment of the patient should be included in the clinical documentation, because it helps auditors to evaluate the severity of the patient’s condition, based on the physician’s analysis and interpretation. However, a patient assessment is not the same as a diagnosis, reminded Ms DeConda, who said that it is not necessary to “write a novel”—just a few sentences are usually sufficient for a patient assessment.

In addition, the practice of cutting and pasting notes in EMRs should be handled with caution, advised Ms DeConda. Healthcare professionals often use cutting and pasting in EMRs to avoid recreating every part of the patients’ medical histories each time patients come in for an office visit. Although Medicare allows this type of documentation to a degree, practices must be careful not to cross the line to the illegitimate use of this practice. Practice managers should establish a policy regarding how much copying and pasting providers are allowed, and ensure that everyone in the practice is aware of this policy, recommended Ms DeConda.

“You’ve got to have a policy going back to the core of compliance,” she said.

Establishing Medical Necessity

The application of medical necessity is not a straightforward set of operating policies and procedures, and there is lack of published guidance on the topic. Consequently, documentation through an EMR may not meet the medical necessity required to support the appropriate level of service.

“Documentation created through an EMR typically fails to reach the level of complexity of care that was provided behind the closed door with the patient. The problem is that we are unable to evaluate what went on behind the closed door, said Ms DeConda. “It goes back to what the provider chooses to include in their documentation; they are ultimately the ones who are responsible for ‘connecting the dots’ to illustrate why they did what they did when treating their patients,” she explained.

However, Ms DeConda questioned whether it makes sense for a clinical legal document to be orchestrated to someone who is not a clinician just so that it can support reimbursement.

“Documentation is expected to paint a portrait of the patient to drive medical necessity every single time. It appears that this would be to make the task of auditing provider-based services easier for the Centers for Medicare & Medicaid Services (CMS), as only one encounter needs to be evaluated, instead of an entire course of patient care. All the while, reimbursements continue to be reduced,” said Ms DeConda.

Changes to CMS’s Claims Processing Manual are adding to the complexity of the situation. A 2003 version of the manual (an internet-only version) stated that the Evaluation and Management (E&M) code selection was formed by the Current Procedural Terminology descriptor of the code. However, in 2004, the language in the manual changed to indicate that medical necessity is the overarching criterion factor in E&M code selection.

Rheumatology is a specialty in which E&Ms are the “bread and butter” of the practice, said Ms DeConda. Because rheumatology practices routinely see patients who have complex medical conditions, it is essential that they are able to demonstrate that complexity through their documentation.

“While I was recently working with a rheumatology practice, the physician told me that he would not change his clinical documentation to conform to a coding instrument. While I agree wholeheartedly with his opinion, we are at a place in healthcare where it has become necessary to either document with a coding approach in mind, or be willing to defend and appeal,” said Ms DeConda. “Both options increase the cost of doing business and negate the focus on prevention, curing, reversing, and managing disease processes of our patient base, but unfortunately, this has become the focus of the carrier interest in the healthcare industry,” she added. 

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