5 Documentation Dos and Don’ts That Reduce Risk

September 26, 2018

As our consulting team reviews thousand of medical records each year, we see a consistent list of common documentation issues that present themselves in practices of all size and specialty.
Here are 5 of the most common dos and don’ts we find ourselves explaining to clients.

1. DON’T choose E/M codes based on the amount of documentation the EHR produces.

This may seem like a no brainer. But you’d be surprised how often we see physicians choose higher-level codes when the note is voluminous in page count but lacking in terms of the documentation details required to meet the level of code.
Remember: You must choose an E/M code based on what is medically necessary for the current encounter. That varies depending on the history, examination, and medical decision-making – not the number of pages that print from the EHR.

2. DON’T use the EHR to auto-populate information from the patient’s last visit – unless it’s clinically relevant to the current visit.

The automatic “pulling forward” of notes from a previous visit may seem efficient when the clinic is busy. But using this feature and failing to customize the note with the unique reason for the visit can be dangerous. That’s because every encounter note must be unique.
The right way to use the auto-populated notes from a previous visit is to modify them to reflect the reason and current issues in the current visit. We advise using the “comments” field to express specific discussion points and details that make the encounter distinct.

3. DO evaluate your EHR template use.

If you haven’t customized your templates, it can result in every note looking the same, which is called “cloning” of the note. If a patient’s documentation looks the same, visit after visit, this will not serve you well in an audit.
The fix? Customize your EHR templates for the most common diagnoses and conditions you treat. Make sure any template has room for additional text and use this liberally to make each note unique to that individual patient and problem.

4. DON’T forget to document the use of a scribe.

Scribes document patient encounters in the record on a provider’s behalf. They never work independently. Payors expect that the provider they reimburse for services is the same person who created the note and delivered the service. Here’s how to correctly reconcile these two facts in any provider documentation for which a scribe was used:
– Enter the name of the person and add “is acting as a scribe for Dr. X” in the note.
– Direct the scribe to sign the note. Everyone must authenticate his or her own entry; scribes are no exception.
– Be sure the provider signs the note indicating that it is an accurate record of all discussion and actions take during that visit.

5. DO regularly review documentation for level 4 and 5 codes.

Payors use algorithms and analytics tools to spot outlier coding patterns and target them for review and potential payback. Level 4 and 5 E/M codes are particularly in their line of sight.
To make sure you’ve properly documented your level 4 and 5 codes, conduct a quarterly internal review. Randomly select 10 patients for whom each provider billed a level 4 or 5 code in the last 6 months. Review the documentation against E/M service criteria and verify that it matches the level billed. If it doesn’t, provide the physician-specific feedback about corrective action.
We advise groups to conduct peer-to-peer, “blind coding” reviews several times a year to make sure correct documentation techniques are understood and being followed. Physicians review say, five samples of their colleagues’ notes, choose the code they think supports each, and compare that to what was actually billed. You’ll be surprised how much you learn from each other.
What if you do your best to code and document correctly, but a payor still targets you? Teri explains what you can expect here.
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