Proper documentation helps withstand Medicare audits

By Paula Hartman-Stein, Ph.D.

HONOLULU- If your handwriting is sloppy and you rarely type your chart notes, you run the risk of a poor outcome if audited by Medicare. Legibility of chart notes is one of the most critical elements in the event of a Medicare audit, according to Jim Georgoulakis, Ph.D. (San Antonio).

Speaking at a symposium on Health and Behavior codes at the APA convention held in Honolulu, Georgoulakis said, although this sounds paradoxical, "The easier the record is to audit, the less likely it will be audited in great detail."

As part of a mock audit during the symposium, Georgoulakis, the APA representative to the Relative Update Committee of the American Medical Association, critiqued an example of an actual case progress note written for an intervention covered by one of the six Health and Behavior codes available to psychologists and other healthcare professionals since 2002. One of the other symposium panelists (the author) submitted the note for his review as part of the interactive presentation.

An auditor typically reviews a record for 14 administrative requirements before the clinical content is examined, according to Georgoulakis. Passing five or six initial criteria often determines whether the chart is subjected to additional in-depth scrutiny. Besides noting the legibility of the record, the auditor checks if the procedure described is a covered service, identifies whether the patient is eligible for the benefit, matches the date of service in the clinical record to the date on the claims form, tracks the number of sessions during that episode of treatment, and looks for start and stop times of the treatment session.

Because Medicare audits can go back ten years, and code numbers and especially code descriptors can change, Georgoulakis recommends listing both the code number of the clinical service, number of units of time, and code descriptor (e.g., 96152 x 4 units, Health and behavior intervention) as well as the diagnosis number and descriptor (e.g., ICD-9-CM 414.00, coronary atherosclerosis). Georgoulakis recommended against the use of V codes for health and behavior interventions, such as artificial replacement of an aortic valve. Given the large number of potential diagnoses allowed when using H and B codes, he highly recommends that each clinician have access to the complete ICD-9-CM.

An indicator of the patientís status is required on all case progress notes. The Global Assessment of Functioning (GAF) is a standard measure acceptable for both psychiatric procedures such as psychotherapy as well as Health and Behavior interventions. Behavior or symptom checklists are also acceptable additional measures.

In order to authenticate the record the therapist must include a signature, title, and date. In a full chart review the auditor looks for dates of follow up and documentation of any missed sessions. The record should contain only well-known abbreviations or acronyms.

In the second part of an audit, the emphasis is on clinical requirements such as how the intervention alleviates or mitigates the medical condition. The treatment should be described in behavioral terms, documenting outcome and patient homework. Medications taken should be noted, along with prognosis of outcome.

In the sample chart note reviewed by Georgoulakis, the treatment emphasized the mitigation of the impact of coronary artery disease on function in daily life in order to prevent excess disability. The progress note described coping thoughts and calming self-talk the patient could use to reduce her anxiety about physical sensations by differentiating expected focal muscle tightness in the chest after a stent procedure from prior symptoms of overwhelming chest heaviness and tightness that need immediate medical attention. Deep breathing and other relaxation techniques were described. The key for all records for Health and Behavior services is to describe a linkage between the treatment plan and patient outcome, according to Georgoulakis.

In his role of discussant at the symposium Ron Levant, Ph.D. APA president-elect said that in his travels throughout the country few have even heard of these codes and fewer still use them. He pointed out that these codes are a "use it or lose it" situation. He assured the audience that the APA Practice Directorate stands ready to help when there are difficulties getting reimbursed for the H and B codes.

National Psychologist Vol. 13, No. 5, Sept/Oct 2004, p. 11

Paula Hartman-Stein is a consultant in private practice in Kent, Ohio and Director of Geriatric Psychology at Summa Health Systems in Akron. Current President of APA division 12, section 2(Clinical geropsychology) she can be reached through her website,