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QIO TRANSMITTAL SERIES ISSUE: Medical Record Issues - Printable
pages Medical Record Requirements Unless otherwise specified, a complete medical record must be
provided for QIO review or project data collection. A complete medical record consists, at a minimum, of the
following: 1. Face sheet 2. Discharge summary 3. History and physical examination 4. All physician progress notes and orders 5. Consultations, operative reports 6. Operative consents 7. All laboratory, x-ray and other
diagnostic study reports 8. Therapy documentation 9. Nurses notes, including medication sheets
and graphics sheets 10. Social service/discharge planning notes 11. Emergency room record At QIO discretion, additional items/information
may be required. It is recommended that hospitals follow the "Principles of
Documentation" developed jointly by representatives of the American
Health Information Management Association, the American Hospital Association,
the American Managed Care and Review Association, the American Medical
Association, the American Peer Review Association, the Blue Cross and Blue
Shield Association, and the Health Insurance Association of America: 1.
The medical record
should be complete and legible. 2.
The documentation
of each patient encounter should include: the date; the reason for the
encounter; appropriate history and physical exam; review of lab, x-ray data,
and other ancillary services, where appropriate; assessment; and plan for
care (including discharge plan, if appropriate). 3.
Past and present
diagnoses should be accessible to the treating and/or consulting physician. 4.
The reasons for and
results of x-rays, lab tests, and other ancillary services should be
documented or included in the medical record. 5.
Relevant health
risk factors should be identified. 6.
The patient's
progress, including response to treatment, change in treatment, change in
diagnosis, and patient non-compliance, should be documented. 7.
The written plan
for care should include, when appropriate: treatments and medications,
specifying frequency and dosage; any referrals and consultations;
patient/family education; and specific instructions for follow-up. 8.
The documentation
should support the intensity of the patient evaluation and/or the treatment,
including thought processes and the complexity of medical decision-making. 9.
All entries to the
medical record should be dated and authenticated. 10.
The CPT/ICD-9 codes
reported on the health insurance claim form or billing statement should
reflect the documentation in the medical record. Requests
for Medical Records
Routine
requests for medical records selected for offsite or onsite review or project
data collection will be made on a monthly or bimonthly basis. In addition, other requests for medical
records will be made as necessary for the QIO to perform its QIO
responsibilities and/or comply with CMS requests/requirements. As
cases are selected by CMS from national files, patient names may be
unavailable in some instances. If the
patient name is not available, the patient's HIC number will be entered in
the column for the patient name. Records
requested for offsite review or project data collection should be mailed to
NHCQF office. Records should not be
faxed. When the QIO requests a copy of the medical record, the copy must be provided within 30 days of the date of the request. If, in the course of review the QIO finds that documentation essential to the review is missing from the record or is illegible, the QIO will request that the documentation be supplied to the QIO within 15 days of the request. Hospitals will be notified of potential denial of coverage if the copy of the medical record or the requested documentation is not received by the QIO within the specified time. Failure to provide the requested complete copy or the requested documentation within the specified timeframe will necessitate technical denial of the claim. The technical denial will be reversed upon receipt of the requested information. If the hospital cannot meet the deadlines, the hospital should contact NHCQF to arrange for an extension.
The
national clinical data abstraction center (CDAC) under contract to the
Centers for Medicare & Medicaid Services, also issues periodic requests
for copies of medical records. These
copies should be sent directly to the CDAC.
Records requested by the CDAC are subject to the same deadlines and
requirements as those selected by NHCQF.
If records are not received by the CDAC after 15 days, the CDAC will
send a reminder notice to the hospital.
The CDAC may also contact the hospital by telephone if information is
missing from a medical record. If
records are not received by the CDAC after 30 days, the CDAC will notify
NHCQF. NHCQF is required to issue
technical denials for any cases not received by the CDAC within the allotted
timeframe. NHCQF is required to issue
these denials within 46 days of the original request by the CDAC. If a hospital cannot meet the deadlines,
the hospital should contact NHCQF to request an extension. NHCQF will discuss the request with the
CDAC and will then advise the hospital of the decision on the extension
request. The hospital should contact
the CDAC directly if there are problems identifying the cases on the request
list or for questions concerning reimbursement for copies of records. Requests for Copies of Medical Records for Review of Hospital Issued
Notices Due to the fact that review of hospital issued notices of noncoverage
must be performed by a QIO Physician Consultant, this review will be
conducted offsite. The majority of
hospital issued notice reviews will be conducted on a retrospective basis. Hospitals are responsible for forwarding
copies of all notices of noncoverage, reinstatement, rescission or deemed
admission to the QIO within 3 working days of issuance of the notices. The medical records will be requested via
the QIO monthly medical record request. If
a patient, while still an inpatient, requests QIO review of a notice of
noncoverage, the hospital must provide a copy of the medical record to the
QIO by the timeframe specified by the QIO representative during the telephone
request for the record. If an immediate
review is requested in the required timeframe by the patient and/or patient
representative, the hospital must provide a copy of the medical record to
NHCQF as soon as possible; the hospital should be aware that it may incur
additional financial liability when the requested medical record is not
provided in a timely fashion.
Hospitals should also provide records by the next working day after
the request for expedited reviews so as to not infringe upon the patient’s
right to a review. In expedited
review cases, the hospital's liability is not affected by the provision of
the medical record. Overnight
mail/special delivery charges are acceptable and will be reimbursed by the
QIO for all cases involving immediate or expedited reviews. Reimbursement for Copies of Medical Records As
determined by CMS, hospitals will be reimbursed for copies of medical records
at the rate of 12 cents per page for all records requested from facilities
reimbursed under a prospective payment system (PPS). The actual postage or estimated first
class postage (if actual postage is unavailable) will be paid. If hospital delays necessitate overnight
delivery to ensure receipt by the QIO by the deadline, the hospital is
responsible for the additional cost of this delivery. Hospitals will not be reimbursed for copies
of records that were not requested by the QIO. Non-PPS reimbursed hospitals will not be reimbursed for copies
of medical records. Routine
requests for medical records will consist of a case listing and individual
request sheets. In order for hospitals
to receive reimbursement for copies of medical records and postage costs,
hospitals must complete the individual request sheets by entering the number
of pages photocopied for each record.
It is not necessary to provide any other information on these sheets
which are standard forms required for use by all QIOs. NHCQF will enter the postage costs on
receipt of the records. The sheets must be returned to NHCQF with the medical
record copies. For any cases where
NHCQF has not provided individual request sheets, the hospital must submit a
list of the records copied including the patient’s name, dates of stay and
number of pages copied. Copies must be complete, legible and in order. Please note that the CDACs use a similar
request package. Hospitals should
follow the CDAC’s instructions when sending records to them. Hospitals
will be reimbursed for the record copies within three months of NHCQF’s
receipt of the records. NHCQF will
include a summary sheet listing the records provided, the number of pages and
the postage with each reimbursement check issued. Reimbursement will be sent directly to the facility the records
were requested from. It is the
hospital’s responsibility to reimburse any photocopying service used. June
2006 Next
Chapter: Required Review Activities |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
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