In Part 2 of this series on the challenges encountered in chart reviewing for risk adjusted conditions, we’ll discuss the prior PCP. Every single primary care practice has a mechanism for requesting and obtaining records from the patient’s prior primary care provider. Of course, there is great variability in the processes, follow through and success in obtaining records.
Additionally, every practice has different guidelines for what it will release. Some PCP offices release only their created medical visit notes, while others release PCP notes and labs. Still others release the whole chart, or every document for the last two years. You really don’t know what you’ll receive although your medical records request form should state what you want (which should be all documents for X period of time).
When receiving prior PCP records, it’s important to review them with a critical eye. We’ve blogged before about providers who report conditions that have no evidence to support them and so, incorporating a condition into your new patient’s chart because “the prior PCP said so” is a recipe for recoupments.
To be honest, when we review charts, we take a cautious approach with old PCP notes, relying on them only to provide clues that will be validated elsewhere in the record. For example, the prior PCP says the patient has pulmonary hypertension and cites an echo result. We use that to track down the actual echocardiogram report and would never suggest the condition to our client based on only hearsay. Some might take that as evidence, but what if the PCP did not adhere to the proper medical criteria for diagnosing this condition? Or what if the PCP’s note contains a typographical error? You would be perpetuating erroneous information for your company. If you’re lucky enough to receive lab and imaging reports, you’re close to a goldmine of information that can bolster your work as an MRA reviewer.
In Part 3 of this series, we’ll explore specialists’ notes. If you missed Part 1 of this series on suspect reports, here’s the link.