Chapter 4 — Further Reading

Tier 1 — Verified canonical sources

Medicare Program Integrity Manual, CMS Publication 100-08, Chapter 3. The signature requirements in §4.4 come from here, along with the rules on signature attestation, illegible and missing signatures, and what a reviewer does when documentation is unauthenticated. This is the document an auditor is working from. Read the signature section once, properly; it is a few pages and it will prevent an entire category of loss.

Medicare Program Integrity Manual, Chapter 3, on documentation requests and medical review. How a contractor selects, requests, and evaluates records. Chapter 37 returns to it.

HIPAA Privacy Rule, 45 C.F.R. Part 164, Subpart E — specifically § 164.501 (the definition of designated record set), § 164.524 (right of access), and § 164.526 (right to request amendment). The source of §4.8.

Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 — the statutory basis for the electronic health record incentive programs described in Case Study 1.

Office of Inspector General reports on electronic health records and fraud vulnerabilities, including its work on copy-paste and over-documentation features, hospital EHR audit-log and copy-paste policies, and the concentration of higher-level evaluation and management billing. Free at oig.hhs.gov. These are the documented basis for Case Study 1, and they read more plainly than most people expect.

Medicare Administrative Contractor guidance on cloned documentation. Most MACs have published an article; find your own contractor's. The recurring formulation — that documentation is cloned when each entry is identical to previous entries, and that cloned documentation does not demonstrate the medical necessity of the specific encounter billed — is the sentence to know.

AHIMA practice briefs on query practice, and the joint AHIMA/ACDIS guidance on achieving a compliant query. The rules in §4.9 come from here. Query practice is one of the few areas of this profession where the governing standards are professional guidance rather than regulation, and this is the guidance.

AHIMA guidance on amendments, corrections, and deletions in the health record, and on defining the legal health record. §4.5 and §4.8.

2021 Evaluation and Management office visit guidelines (AMA CPT E/M guidelines and the corresponding CMS rulemaking) — the reason ROS and history are no longer office visit level drivers. Chapter 15 covers them in full; the relevance here is Case Study 1's causal argument.

Tier 2 — Attributed, specifics unverified

ACDIS (Association of Clinical Documentation Integrity Specialists) materials on query practice, concurrent review, and CDI program design. Chapter 38 uses these more heavily. Some material members-only.

Health services and informatics literature on copy-paste prevalence in electronic notes. Multiple studies have measured the proportion of note text that is copied or imported rather than newly authored, with findings that are consistently high and that vary by setting and method. The direction is well established; specific proportions vary by study and should be cited from the study rather than from a summary.

"Note bloat" and documentation burden literature, including comparative work on the length of American clinical notes relative to other countries. The phenomenon is well documented; treat any specific multiplier as study-specific.

Vendor documentation on provenance tagging and copy-forward indicators. If your organization uses an electronic health record with these features, the vendor's documentation will tell you what your audit trail actually captures — which is worth knowing before you need it.

Professional coding association guidance on the coder's role and scope, including on what a coder may and may not infer. §4.7's rule is a synthesis of guidance that is stated in many places and codified in none.

Tier 3 — Illustrative and constructed

Figure 4.1 — the paired leading and compliant queries. Constructed. The clinical scenario (post-operative hemoglobin drop with transfusion) is a realistic and common query subject; the specific values are invented.

Figure 4.2 — the March 14 progress note for Account 10-4471. Constructed in full. It is the canonical note for this book, and every code assigned in Parts II and III derives from it.

Case Study 2 in its entirety — the four-physician practice, the twenty-claim review, the nineteen denials, and the two-year exposure. A composite constructed from documented Medicare medical review findings and published contractor guidance, and labeled as constructed within the case study. The requirements it describes are real; the practice is not.

If you read only three things after this chapter

1. The signature section of the Medicare Program Integrity Manual, Chapter 3. A few pages. It is the most cost-effective reading in this entire book relative to the money it protects.
2. Your own contractor's cloned documentation article. Ten minutes, and it tells you the exact language a reviewer in your jurisdiction will apply.
3. The AHIMA/ACDIS guidance on compliant queries. If you will ever send a query — and every coder will — this is the standard you will be measured against, and it is more specific and more usable than §4.9 could be in the space available.