I get frustrated when I see people try to squeeze an entire person into a series of checkboxes. This has gotten under my skin for a long time. Apparently, Medicare agrees with me. Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.
The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time. I provided the bold text.
The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM 184.108.40.206 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.
The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.
CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.
Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.
Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.
If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.
So, be wary of programs that do too much for the nurses. If a program doesn’t require at least a short narrative, it likely will not get done. If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.
Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information. You need reports and communication. You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.
You do not need any more denials. I assure you.