Technicians as the First Line of Defense in Diagnostic Testing
Documentation For Diagnostic Testing: How Technicians Help Protect Your Practice During an Audit.
When we talk about diagnostic testing, a lot of attention naturally goes to the physician, the diagnosis, and the final results. But there is another person who plays an incredibly important role in making sure the process works the way it should: the technician. Technicians are often on the front line of diagnostic testing. They are the ones working directly with orders, patients, testing protocols, images, and documentation. And when an audit happens, the details they capture along the way can make a major difference. That is why documentation is about much more than simply completing a form. It helps tell the complete story of why a test was performed, how it was performed, and whether the documentation supports the service that was billed.
It Starts With a Valid Order
Before the test even begins, the order matters. If an order is incomplete or invalid, problems can follow later when a claim is submitted or reviewed. That makes it important to verify that the necessary information is there from the beginning. Technicians should understand what information needs to accompany the test and recognize when something may be missing before moving forward. Catching a problem early is much easier than trying to correct it after a claim has been denied or an audit request has arrived.
Not Every Audit Is the Same
Healthcare organizations may encounter several different types of audits and reviews. These can include HEDIS reviews, risk adjustment audits, utilization reviews, prospective audits, retrospective audits, and other payer-specific reviews. Each one may be looking for something slightly different. That is why it is important for technicians and the rest of the healthcare team to understand what documentation may eventually be requested and to make sure it is being collected and retained appropriately. A technician may not be responsible for managing the audit itself, but the documentation created during the testing process can become an important part of the response.
Documentation Creates a Clear Trail
One of the simplest ways to think about documentation is this: Could someone who was not there understand exactly what happened?
The medical order, diagnosis, physician documentation, test performed, images, results, technician information, and other supporting records should work together to create a clear and consistent picture. If pieces are missing or do not match, questions can arise during a claim review. Good documentation helps connect those pieces.
Diagnostic Testing Requires Checks and Balances
Technicians should also be comfortable performing basic checks before and during diagnostic testing. That can include confirming that the correct patient and identifiers are present, reviewing the order, making sure the requested test matches what is being performed, and ensuring the necessary information is captured and retained. The diagnosis information also needs to make sense in relation to the physician's documentation and the medical necessity of the test. These may seem like small details in the moment, but during an audit, those details can become extremely important.
Understanding LCDs and Coverage Requirements
Medicare's Local Coverage Determinations, commonly known as LCDs, can be valuable resources for understanding coverage and documentation requirements for certain services. Related Local Coverage Articles may provide additional guidance.
Because requirements can vary depending on the service and jurisdiction, healthcare teams should know where to locate the applicable guidance and periodically review it for changes. Technicians do not need to become billing experts, but having a basic understanding of the requirements surrounding the tests they perform can help prevent avoidable problems.
Communication Makes the Entire Team Stronger
Compliance should never fall on one person. Physicians, technicians, billing teams, administrators, and compliance professionals all contribute different pieces of the process. When those teams communicate well, problems are much easier to identify before they become larger issues.
If something does not look right with an order, ask.
If documentation is missing, address it.
If requirements have changed, make sure the people performing the work know about those changes.
Creating that type of communication and accountability helps protect the practice while also making the entire workflow more efficient.
Technicians Really Are the First Line of Defense
Technicians may not always be the first people who come to mind when discussing compliance and audits, but their role is incredibly important. The information captured during diagnostic testing can ultimately help demonstrate that a service was ordered correctly, performed appropriately, medically supported, and properly documented. That makes the technician one of the earliest opportunities to catch an issue before it becomes a denial, repayment request, or audit problem.
And in healthcare compliance, catching a problem early can make all the difference.
Watch the full video above for a deeper discussion on the technician's role in diagnostic testing, documentation, and audit preparedness.
If you have questions about this topic or would like MEDCO to cover another area of healthcare compliance, reach out to our team and let us know.