Documentation Challenges in Peer/Utilization Review

Over the past several months, numerous providers have contacted me with problems and questions regarding peer/utilization review. The phone calls have come from all over the country, indicative that there is much confusion about this hated insurance mechanism. My last few articles have attempted to clear up some of the misunderstanding, but it is apparent that most practitioners are still uncertain of what is expected of them.

Many doctors are surprised to hear that peer review has little to do with the condition of the patient. Things like patient improvement, diagnoses and documentary literature surrounding treatment efficacy are all secondary to whether the documentation within the file support the need for the treatment provided. This is the fundamental difference between a paper review (like peer and utilization reviews) and independent medical examinations. While often used interchangeably, IMEs are physical examinations of the patient, while peer/utilization reviews are essentially "audits" of the provider's documentation.

Doctors are often frustrated by these paper reviews because they feel that the patient's well-being is paramount, whether or not the provides can keep good notes. But in this age of claims adjusters "looking over your shoulder," office notes have become (and really always were) legal documents. These documents must support the need for care on an ongoing basis, from the date of your initial consultation through your most recent office visit. Practice parameters which dictate what "most" chiropractors do in their offices take this one step further, creating an accepted standard for what your documentation should provide.

I would like to address some of the complaints which I have heard regarding the denial of claims from inadequate documentation:

"It's impossible to document cases the way reviewers demand."

I will clarify this opinion. It is difficult to provide adequate documentation when a doctor has a high-volume practice. This was the reason that travel cards were born and continues to be one of the primary reasons cases are denied. That you can't get the appropriate documentation down on paper is no rationale for arguing with a reviewer. I have the same answer for any high-volume practitioner who has problems documenting cases sufficiently: dictation!

Dictation is the way to go for almost any practitioner seeing any number of patients. The quality and thoroughness of dictation far outweighs travel cards, check-off systems, computer generated notes and handwritten entries. It is legible, pertinent and easy to do. Consider it.

"The medical doctors wouldn't send their notes to me."

It doesn't matter. As a provider, you are responsible for having all pertinent documentation. (Think about it. If a patient says they have a herniated disc and you can't get the report, how do you know that's what the patient has? What's the position? Is there thecal sac compression?) Often peer review organizations do not obtain documentation from other providers, leaving the reviewer with only the chiropractic file. Include all relevant notes when submitting your case!

My suggestion is to have all patients sign a medical release. On a patient's first visit, have your office staff fax the release to the appropriate providers and have them mail or fax you copies of their records. If you still can't obtain the appropriate documentation, then enlist the help of the patient. It is ultimately the patient's responsibility to obtain information that you require. This is essential!

"My notes state that the patient would only be seen on a PRN basis!"

My last article dealt specifically with supportive care and provided the parameters for establishing the need for such care. Supportive care requires specific documentation without which there cannot be a claim for treatment beyond maximum medical improvement. Elements of supportive care include trial withdrawals, a diagnosis which progressively deteriorates without your care, and treatment provided solely on a patient-requested basis.

Too many doctors document the need for "PRN" or "as needed" care without carefully understanding the parameters for supportive care. Such ongoing treatment requires a concerted effort on the part of the doctor to adequately convey the necessary information.

"I made referrals during the course of the patient's treatment." That's fine, but the referrals still have to be supported by the documentation and have sufficient clinical rationale. An example of an inappropriate referral might be the doctor who orders a lumbar MRI when the file reflects a negative SLR, symmetrical deep tendon reflexes, no motor weakness and radicular pain to the buttock. With any referral, be it imaging study, electrodiagnostic testing or professional second opinion, there must be appropriate reasoning documented in the notes. (Note: That the patient's attorney needs a referral to "build the case" is not any rationale for any referral!)

I recommend that you make it a rule that anything done outside of a normal daily routine (SEMG, prescription for durable medical equipment like cervical pillows, lumbar supports, professional referrals, etc.) be accompanied by a separate, short entry in your file explaining the rational for your decision. This gets you in the good habit of proper documentation and defends your actions in peer review situations.

"The patient has had multiple exacerbations which have prolonged care."

Again, all exacerbations should be detailed in the notes, stating exactly what happened, what effect it had on the injury and the estimated time it would take to bring the patient to pre-exacerbation status. Recognize that many providers use every cough and sneeze as rationale for prolonged treatment. This is not considered appropriate chiropractic management, especially without substantial supporting documentation.

This is especially true for minor or uncomplicated injuries. It is very difficult to support an assertion that minor soft-tissue trauma will require six months of treatment, regardless of exacerbating factors. When there is documentation reflecting multiple exacerbations over the course of care, questions begin to fly.

There is no question that documenting patient files has become more demanding over the past few years. In my opinion, this demand has been necessary to correct a history of poor documentation which did not substantiate treatment regimens. However, as stated in many forums, the key to winning peer reviews is in providing outstanding documentation which reflects treatment falling within accepted guidelines. It can be done, and you can do it. However, no one ever said it would be easy.

Steve Freeman, DC
Diplomate, American Board of Quality Assurance and Utilization Review Physicians
Philadelphia, Pennsylvania
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