Podcast Episode 12: Bulletproof Documentation
Episode Summary
Medical Documentation has suffered a decline in integrity due to adoption of Electronic Medical Records and an incomplete understanding of Documentation Guidelines. Hosts Neal Sheth and Dr. Piyush Sheth explore this topic and provide solutions that can strengthen your medical record documentation and make them stand up to scrutiny during audits.
Episode Transcript
NEAL SHETH: Hi Dad.
PIYUSH SHETH: Hi Neal.
NEAL: Unraveling Medical Coding is about Improving Documentation, Coding Intelligently, and Minimizing Audit Risk. This episode is about Medical Documentation and improving integrity of the medical record while minimizing the risk of an audit and allegations of fraud. No discussion on this topic would be complete without mentioning “upcoding” and “fraud”, so let’s define these terms. Upcoding is the assignment of a higher-level billing code without supporting documentation in an effort to increase reimbursement, and Fraud is an intentional deception or misrepresentation that is reported knowing that it is incorrect.
This episode is not meant to be an all-encompassing discussion on the topic but we hope to start a discussion.
So, how do we Bulletproof Medical Documentation?
Dad, why don’t you get us started.
PIYUSH: Sure. The goal of today’s episode is not to tell you what to document but to tell you how to document. I have 5 simple rules that if followed will enrich your documentation.
RULE #1: KNOW THE RULES
According to CMS, the overarching criterion for payment is Medical Necessity and documentation must support that medical necessity. For example, an ingrown toenail is usually not be billed as a level 4 or 5 encounter. You simply cannot justify a level 4 or 5 billed service for such a minor diagnosis. You could theoretically spend a lot of time with the patient and document a very extensive visit note but it would be considered inappropriate since it would not meet the medical necessity criterion.
There are documentation guidelines from 1995 and 1997. I highly advise listeners to download them and become familiar with them. Sift through them and look for the fine print. Documentation of Review of Systems, for example, has certain stipulations.
a. In the office you can have the patient fill out a ROS form that you review and sign. This can be attached to the patient’s medical record chart. This will save you a lot of time from having to go through a detailed ROS line item by line item with the patient.
b. There are a total of 14 systems that can be reviewed. Don’t use statements like “10 systems were reviewed, pertinent positives and negatives listed and all other systems are negative.” This documentation does not list which 10 systems were reviewed and therefore the statement is ambiguous and credit cannot be given for the ROS. It is much cleaner documentation to list out which 10 systems you reviewed. Or if you reviewed all 14 systems, then document “All 14 systems were reviewed and pertinent positives and negatives are as follows…” then list out those positives and negatives.
NEAL: Aren’t there 2021 Office Documentation Guidelines that one should review?
PIYUSH: Yes, absolutely! There is a lot of fine print in there also. For example:
a. Independent interpretation of tests does not mean “review of tests”. To get credit for an independent interpretation of tests, you must review the images / tracings and document your personal interpretation.
b. If you take credit during one visit for ordering a test, it includes the subsequent review of the results on the follow-up visit. You cannot take credit for both the ordering and the reviewing of results.
c. All notes reviewed from any single unique source counts once. If a patient visits the ER, reviewing all the notes from that ER visit counts for only one point.
d. Using Time to level a visit may on the surface seems easier but there is fine print. Phrases such as “I spent 38 minutes evaluating the patient” requires supporting documentation of what you did in those 38 minutes. Coding by Time does not excuse you from documentation requirements.
The 2021 guidelines regarding time-based coding are scheduled to be implemented for the hospital inpatient setting in 2023. Let’s see how that goes.
RULE #2: BE HONEST AND DON’T CUT CORNERS, YOUR NOTE IS A MEDICOLEGAL DOCUMENT. TREAT IT AS SUCH.
NEAL: Wait, are you saying providers are dishonest?
PIYUSH: Not at all. All providers go into healthcare with good motives. However, the deluge of rules on documentation and the widespread use of EMR’s have been railroading providers into developing poor habits. Let me illustrate this with some examples. Physicians are usually taught to use blanket statements, templates, and dot phrases to minimize documentation time.
Here’s a blanket statement I see quite often:
“I have personally reviewed the past medical, past surgical, social, and family history with the patient and updated them as necessary”.
Using this statement is okay if you actually reviewed the information. Auditors are hyperaware that sometimes physicians do not review these portions of the medical record. If the Past Medical or Surgical History contains errors such as two entries for hysterectomy or 3 entries for diabetes, it is hard to imagine that the provider reviewed them. The statement and the entries cannot be reconciled, since these errors would have been easily noticed and corrected. When these discrepancies occur, it could lead to allegations of fraud.
NEAL: So how prevalent is this type of blanket statement?
PIYUSH: I see it being used at least more than 50% of the time in the office setting.
NEAL: Do you also see the errors in the medical and surgical histories?
PIYUSH: Unfortunately, all too often.
EMR templates are another way to speed up documentation but often the templates are generic. In some, by simply clicking one box or using a dot phrase, you can automatically document a full 14 system review whether you did it or not.
Using the same generic template on every patient is inappropriate. The physical exam is another problematic section. You should only include those elements in the physical exam that you personally performed, and it should be accurate. One of the most egregious examples of misuse of a physical exam template was a patient I saw who had symbrachydactyly. He was born with only 3 fingers on each hand, yet numerous notes in the chart referenced extremities with no deformities and the past medical history made no mention of the symbrachydactyly.
Disclaimers, like blanket statements, also should be avoided. A common disclaimer used is:
“This note was transcribed using a voice recognition software. Please excuse any sound alike substitutions and misspelled words in the context of the information presented.”
From a legal standpoint, providers should verify that the information is accurate and complete prior to signing the note. Your note is a medico-legal document. Using disclaimers does not absolve you from the medico-legal consequences of inaccurate documentation. At our organization, I asked our compliance department to weigh in on this and they sent it to legal who affirmed that providers should not be using this disclaimer. Speaking of lawyers, those that litigate malpractice cases are zeroing in on this type of disclaimer as a way to discredit you at trial essentially claiming that you don’t care enough to check the accuracy of your notes and your propensity to making errors.
NEAL: This is getting quite interesting. What’s rule number 3?
RULE #3: BE CLEAR
Avoid ambiguous statements. Here are a few I’ve seen over the years:
“Time spent with family or surrogates is included only if the patient is incapable of participating, and if the purpose was to collect necessary information or to discuss treatment options.”
“If the patient was a smoker, then I counseled them on cessation.”
These statements are ambiguous, and it is unclear if the physician actually performed the action.
Here is another new ambiguous statement I’ve seen pop up due to the current push by Medicare and the AMA to minimize documentation burden on physicians and allow them to bill by time. In this example, a physician was documenting a shared/split visit note with an APP:
“Please link this note as an addendum to the APP’s note on the same day of service…Furthermore, even though we both were involved with evaluating this patient today, my participation and time spent has exceeded 51% of the total time spent”.
How much actual time did each provider spend in evaluating the patient? How much over 51% of total time was spent? Unless the answers to these questions are clearly documented, the APP would bill for the visit and not the Physician. A much clearer way to document involves listing the exact number of minutes that each provider spent evaluating the patient.
Finally, use clear terminology if possible and avoid using words such as “unremarkable” or “non-contributory”. These terms have no meaning and are grossly over utilized. Documentation Guidelines give no credit for statements such as “Family history was non-contributory”.
NEAL: Clarity seems so important. Do you even get documentation credit when you use ambiguous statement?
PIYUSH: No. During an audit, you are given zero credit for using ambiguous statements.
NEAL: Could that potentially invalidate your entire encounter coding level?
PIYUSH: Yes. If an audit negates portions of your note, it may seem as if you upcoded the encounter. Remember our definitions of upcoding and fraud at the beginning of the episode. You certainly don’t want that to happen.
RULE #4 AND #5 go hand in hand: AVOID NOTE BLOAT AND USE COPY-AND PASTE, AKA CLONING, JUDICIOUSLY AND IN AN APPROPRIATE MANNER
Most notes are bloated and are less likely to be read. It is so easy to use a dot phrase to insert entire radiology reports, days’ worth of labs, and even all your assessments in previous notes into your current note in an EMR. Ask yourself, “When was the last time I read a consultant’s full note?” You might be surprised with your answer. Instead of bloated notes, you want notes that are meaningful and succinct, making them readable and pertinent.
Copy and pasting, similarly, can lead to voluminous notes which contain erroneous information often entered by other providers. Instead of “copy-and-paste”, I recommend you instead use “copy-paste-review-and update”. This will ensure that your note is more credible and can stand up to challenges on accuracy and legality.
NEAL: I like those rules. Simple to understand and practical to use. Any parting thoughts?
PIYUSH: So, here’s an excerpt from DeGowin’s Diagnostic Exam, 9th edition that hits the problem dead center:
“An increasing problem encountered with the electronic record is the “cut and paste” phenomena: documentation from one day is cut and pasted to the next rather than constructed anew, and a deluge of laboratory and radiologic information is pasted into daily progress notes and discharge summaries. These are both abuses of the electronic format that are to be condemned. Neither requires that the cutter-paster has actually read the material, given it any thought, or reflected upon the whole of the information to form a new and evolving clinical assessment and management plan. Each daily note should be constructed in its entirety each day, with appropriate references to existing records. The physical findings must be ascertained and recorded daily as they change and evolve. Test results should be succinct summaries of key radiographic findings and the few key chemistry and microbiologic reports used today to make diagnoses or change the management plan. All the detailed radiologic and laboratory information is readily available to everyone reading the note in another part of the record and it need not be duplicated. Electronic records are a boon to patient care when generated and used correctly. Unfortunately, they also facilitate sloppy, expedient but unprofessional and potentially dangerous documentation practices that discourage thought and reflection and perpetuate misstatements, erroneous conclusions and frank errors.”
NEAL: What a fantastic and eloquent quote. For listeners who are interested in reading more about the limitations of Electronic Medical Records, there is an excellent article in the November 5, 2018 issue of The New Yorker titled “Why Doctors Hate their Computers” by Dr. Atul Gawande.
That’s it for this episode. Please check out the other episodes. Don’t forget to rate and review us and subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please share this podcast with friends or colleagues who you feel would benefit from learning about medical coding and documentation. Stay safe and stay healthy.