One of the easiest problems to solve, but one of the biggest problems existing in long term care is getting industry leaders to recognize the importance of qualified medical records staff. Performing my own, informal root cause analysis this week, I determined that the reason my SNF client was unable to produce a complete medical record for a recent Additional Documentation Request (ADR) was because the medical records staff did not understand what was being asked or expected of them.
As I discussed my findings with the Administrator, I could glean his dismay. The facility had several recent documentation requests from the Comprehensive Error Rate Testing (CERT) and upon my review, I found that the medical record was incomplete, lacking required Medicare documentation that was often kept separate from the medical record. The record was disorganized and lacked supporting documentation that should have been included due to the requested look back periods. For example, the service dates to be reviewed were February 1 – 28. The key here is that there was an MDS completed during that timeframe. The ARD was February 1, therefore any and all supporting documentation used to code that MDS should have been included in that particular situation.
True there is no regulation that states the medical records professional must have a certain degree or certification, but let’s think about the responsibilities of this role:
- Ensures your medical records are accurate and complete
- Organizes and maintains the facility’s legal document of care provided
- Coordinates, per regulation, thinning and storage of the legal documents
- Copies and ships documentation to support Medicare and Medicaid claims
It is no surprise to me that the most common F-tags directly relate to these areas. The number one problem facing the long term care industry is the loss of revenue related to denied claims due to improper documentation submitted to support a claim upon review.
Medical Record professionals require education, mentoring and monitoring to ensure accuracy and continued support that enables growth and efficiency. With regulations and the top 5 F-tags being:
- F-279 Comprehensive Care Plans
- F-281 Professional Standards of Care
- F-514 Clinical Records Complete, Accurate, Accessible and Organized
- F-309 Highest Practical Well Being
- F-481 Following the Plan of Care
The strength of your medical records department, survey success and reimbursement depends on how much effort you place in training and development. Achieve positive results for your organization by developing a plan to strengthen your medical records staff. You will want to include:
- Comprehensive Orientation Program
- Continuing Education Program
- Policy and Procedure Review
- Denials Management Process
- State and Federal Regulations Review
- Medical Record Compliance
As documentation and medical record systems increase in complexity due to the multiple changes in our industry, medical record professionals working in long term care facilities need to have the knowledge and resources to maintain health information systems that impact quality of care including regulatory, compliance, financial and potential legal concerns. If the facility is unable to hire or retain a credentialed Health Information Specialist to manage the Medical Records Department, it would be beneficial to ensure there is an outside party to assist in staff development, provide ongoing education, auditing and monitoring and mentorship to increase compliance and reduce your risk of loss related to the multiple regulatory deficiencies associated with a poorly managed Medical Records Department.
Harmony Healthcare International (HHI) is available to assist in developing your Medical Records Department and maintaining compliance within your facility.To contact us, please visit our website at harmony-healthcare.com or call us at (978) 887-8919.