Clinical care documentation that survives auditing

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Jayne Warwick, PointClickCare
Jayne Warwick, PointClickCare

Medicare claims set the stage for reimbursements – they're the cast. Backstage, however, documentation comprises the crew, supporting the claim and determining whether or not the show – the outcome of an audit – goes off without a hitch. Nailing down documentation best practices has become more and more important each year, as the Centers for Medicare & Medicaid Services put long-term care and skilled-nursing claims under increased scrutiny.

Long-term care organizations have always been held accountable to compliance requirements when it comes to documentation. Now, as a condition for participation in federal healthcare payment programs, they must develop and implement an effective compliance plan to ensure they either are prepared for an audit or can avoid one altogether.

The CMS Office of the Inspector General also recently set its sights on skilled nursing facilities. Its 2015 Work Plan identified how skilled nursing facilities are increasingly billed for the highest level of therapy – despite patient characteristics remaining unchanged from previous years when they'd billed for lower acuities – and they will be investigating what caused the uptick in billing.

MACs, ADRs and RUGs

If a Medicare audit contractor cannot make a coverage or coding determination from the information provided on a claim, then providers might need to submit additional documentation and receive an Additional Development Request. The MAC requests records related to the claim(s) being reviewed, and may collect documentation related to the patient's condition before and after a service in order to get a more complete picture of the patient's clinical condition.

ADRs give facilities a chance to supplement existing documentation before CMS determines overpayment has been made. At this point, CMS or other federal agencies are saying that they want their money back – unless you can provide better proof of services at the facility level. Providers must prove those services through proper documentation. If the provider cannot offer sufficient proof, the government will recoup the money. These stem from federal government and programs put in place by CMS.

CMS looks at claims with high Resource Utilization Group scores and are asking providers if they are performing the minimum services to justify high RUG categories. It's incumbent upon the business side of an organization to engage with physicians and nurses to prevent erroneous claims. High RUG utilization is a focus area for new audits; providers should focus on documentation to make the case for claims.

Tips for building audit-friendly documentation

How can providers survive the audits that federal agencies have said will increase during the coming years?

The answer: By creating detailed, correct care documentation. The goal of documentation is to substantiate daily skilled care. It must be complete, accurate, readily accessible and systematically organized to allow medical reviewers to determine the appropriateness of the billed services.

Documentation that stands up to audits begins with neatness. It counts. More importantly, completeness rules the day.

Here are a few best practices that providers should implement if they haven't already:

  • Write entries legibly and have them signed with credentials.

  • Put events in chronological order; never chart before giving care.

  • Be truthful.

  • Document objectively, not to a particular RUG requirement.

  • Make sure documentation in keeping with acceptable nursing practice.

  • Practitioners should only document what they are qualified to do and what is in their scope of practice, including clinical issues, rehab and treatments.

  • Date and time all entries, using “a.m.” and “p.m.,” unless using military time.

  • Avoid red flag language, such as “accidentally,” “by mistake,” or “I think”.

  • Nurses must be sure to document – at a minimum – a complete assessment every 24 hours. We recommend doing this at least twice a day, as each person on duty is going to see something a little bit differently; this will allow for a more complete picture of the resident.

Clinical decision making also plays a role in documentation. A provider should be able to communicate how it has met residents' needs. Documentation must also reflect that a practitioner performed a clinical assessment on the resident, which required a higher-level evaluation that precipitated a call for skilled services later on, all of which appeared on the claim.

There are specific items to confirm exists in the documentation before submitting claims:

  • The need for skilled service – rehab or medical diagnosis – make sure to show an auditor that was the reason for the patient's services.

  • All appropriately billed services.

  • All comorbidities, not just issues a resident is there for.

  • Rehab and treatments.

  • ADLs and all functional areas.

  • Cognition and mood – that can help with facility's overall case mix index.

The best defense is a good offense. Handling documentation will protect the organization and its staff from audit problems down the road. It will help prove that patient need, instead of payment incentives, is driving the provision of services.

Creating accurate documentation to justify claims will eliminate fear if a provider is selected for an audit. It will proof the documentation and claims processes, and will confirm the provider is on the right path – especially if it can provide ADRs to satisfy auditors' needs. How can a provider really know it has provided a successful audit response? When the government doesn't take money away in the end.


Jayne Warwick, RN, HBScN, is the Director of Industry Insight at PointClickCare. This piece was adapted from “Audits, ADRs and Documentation,” a webinar sponsored by PointClickCare that included Maureen Hedrick and Jennifer Leatherbarrow, RN, BSN, RAC-CT of Richter Healthcare services. Full archive available here.


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