September 12 2017 | 0 Comments | 176 reads Average Rating: 3

Fallible Humans and Four of Their Documentation Foibles

by EXL Healthcare in Risk Adjustment

The Centers for Medicare and Medicaid Services is cracking down on documentation shortcomings – via risk adjustment data validation (RADV) audits. As such, payers are likely to see reimbursement dwindle if they don’t get their documentation ducks in a row.

Humans, however, are fallible. Indeed, care providers are falling short in this sphere as they:

1) Document in an incomplete or insufficient manner. Physicians typically learn how to fill out a chart or progress note while on the job. Therefore, they learn as they go – and often miss some of the subtleties such as how to link retinopathy to diabetes in a clinical note.

2) Use outdated tools. Documentation errors sometimes occur when providers continue to use old tools, such as NCR forms that do not track the new codes that are developed each year.

3) Hold on to old habits. Many providers are accustomed to documenting clinical encounters in a specific fashion. For example, many physicians are still using ICD-9 codes, instead of the more specific ICD-10 codes. This could create issues that will cause health plans to be penalized if a problem is not recognized.

4) Miss valuable lessons. Sometimes, physicians are just not in the know when it comes to current documentation practices. For example, in some instances, physicians may be coding for Hierarchical Condition Categories (HCCs) rather than for the treatment they performed for the member – simply because they have not been educated in the new documentation norms.

These human errors and oversights often result in documentation shortcomings. Fixing these foibles, however, requires more than human intervention. Indeed, the analytics of a charting validation service can do what no department of humans can do – review every chart and find the anomalies that indicate problems with diagnostic codes or HCCs so they can be corrected before CMS sees them – and starts assessing penalties. In addition to correcting these issues, a chart validation service can also help remediate problems at the source.

Can you think of any other human errors that could be addressed with an automated chart validation service?

Rate this Article:

Average: 3 (2 votes)

EXL Healthcare

Log in to post comments



Arun Rangamani
VP, Payment Services Delivery Leader

Ben Steverman
Chief Technology Officer

David Hom
Chief Evangelist

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

John Pagliuca
Vice President, Life Sciences

Lalithya Yerramilli
VP, Healthcare Solutions

Lesli Adams, MPA (Guest Author)
Director of Population Health Strategy, Oracle Corporation

Linda Pantovic (Guest Author)
Director of Compliance & Risk Adjustment, Scripps Health Plan Services

Mark Feeney
Life Sciences Consultant

Monique Pierce
Vice President, Business Optimization

Nayfe Faillace
Chief Compliance & Privacy Officer

Nicole Stec (Guest Author)
Senior Well-Being Manager, Banner Health

Priyanka Rajkumar
VP - SCIOXpert and Solutions, Analytics

Rena Bielinski
SVP, Strategic Accounts

Rodger Smith
SVP, Payment Integrity

Rose Higgins
SVP & GM, Data and Analytics

Subha Vaidyanathan
VP, Technology and Data Management

Taryn Bevilacqua
Compliance Director


Sign up to receive the latest SCIO news & insights, industry updates, event updates and more, right in your inbox.