Audiologic Reporting and Electronic Medical Records

Question

Answer

A good reference manual to consult is found on the Centers for Medicare and Medicaid Services (CMS) website. The 1997 Documentation Guidelines for Evaluation and Management Services (see www.cms.gov/MLNEdWebGuide/25_EMDOC.asp) includes documentation requirements an auditor expects to find in medical records. They include a patient history and relevant elements of the history to justify why a procedure or evaluation was performed and to convey the medical necessity of what was done. There should be a description of what was performed, what was found, a clinical assessment of what the findings mean, recommendations, the date of service and a signature or signatures. Each professional must stand as an independent provider for documentation purposes. The history section that the audiologist records does not necessarily need to be as extensive as that taken by the physician but must be sufficient to justify why a hearing or balance evaluation was performed. The audiogram cannot stand on its own as the representative document because most auditors have no idea what it means. That is why the description of what was done and what was found is important. The most important section is probably the clinical assessment statement. The recommendations serve as the logical conclusion of the preceding sections. But it really comes down to the observation that each provider who bills is considered independent of all other providers when it comes to documentation.

There are requirements for an audiologist to document hearing loss diagnosis and recommendations noted in Section 80.3 of Chapter 15 in the Medicare Benefit Policy Manual (MBPM)(www.cms.gov/manuals/Downloads/bp102c15.pdf). It is advisable that the audiologist providing services in an otolaryngology practice, at the very least, record those items noted in the Documentation Guidelines and to be sure to include an interpretation of test results. For example, "Audiologic test results revealed a moderate bilateral sensorineural hearing loss." The office manager can always contact the Medicare Administrative Contractor to ensure the practice is in compliance with Section 80.3 of Chapter 15 of the MBPM and the Documentation Guidelines for Evaluation and Management Services.

Dr. Steven C. White has been an audiologist for over 40 years and at ASHA for 30years where he is the director of Health Care Economics and Advocacy. He can be contacted at swhite@asha.org.