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Common Mistakes Associated With Physician Documentation [PODCAST]

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In this episode, Cyndy Kowalski, a manager in our Compliance Services Team at BESLER Consulting, discusses common mistakes associated with physician documentation.
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Michael: Hi, this is Mike Passanante and we are glad you are back onboard for another episode of the Hospital Finance Podcast. Today, I am joined again by Cyndy Kowalski who is a manager in our Compliance Services Team here at Besler Consulting. Welcome back, Cyndy.

Cyndy: Thank you, Mike. It’s good to be here again.

Michael: So today, Cyndy is going to walk us through some of the common mistakes and challenges associated with physician documentation.

In a previous podcast, we talked about essential components of physician documentation and coding. And Cyndy, let me throw it to you. Can you share some of your experiences with common mistakes and challenges around those elements?

Cyndy:  Certainly, Mike. To ensure that a medical record and its documentation is accurate, it’s important to follow certain principles. One is that your record, your medical record is complete and legible, that the documentation of this patient encounter should include the reason for the encounter, history, physical exam, prior test results, diagnostic test results and assessment, clinical impression, diagnoses, a medical plan of care and the date and identity of the person performing the exam.

I think it’s important when we think about some of the challenges and the common mistakes. A lot of them have to do with omission. We’re just not including them. And they could be past and present diagnoses. Maybe the patient is being treated by another physician. You want to be sure that they are documented in the medical record regardless of who’s treating.

You want to be sure that all of the appropriate health risk factors have been identified, the patient has been screened and the factors have been identified. You want to be sure that the patient’s progress, response or any change in the treatment is also documented.

And I think what’s important as I go through some of these common mistakes and challenges is probably to count how many times I talk about documentation because documentation is a significant component of all of this.

Michael: So I want to focus now on each element around documentation. So can you first describe for us specifically what you see?

Cyndy: Generally through education and training, when through an acquisition or a medical staff education, if we’re performing coding audits, based on that dialogue with physicians, with coders, with the billers, we generally hear what some of those challenges are. So we’re able to glean that information if you will. In addition, through our own monitoring of records as well as audits, we have been able to over time track and trend exactly what we see as high priority areas if you will.

Michael: Okay. So let’s start with history and go through some of those common mistakes that you find in that area.

Cyndy: Sure. I think some challenges specifically around the element of history have to do with the history of the present illness. And it’s really rather basic. The history of present illness is just not completed. It’s not completely documented. Again, more of an active omission, it’s important that there be a means to capture all of this type of information.

We also see incomplete documentation and what I mean by that is this incomplete documentation that is not gathered on the initial visit is then used to determine the next level of visit. But if you think about missing information, you’re really not establishing what that appropriate plan of care is.

What we also see around history, present illness is a basic or simply listing of chronic conditions without providing any actual status for the patient. I see that you have a history of asthma, but how are they doing? Is it managed? You have a history of hypertension, “Yes, it’s managed.” You have a history of diabetes, “Yes, but my blood sugars are going up and down.” Simply listing the additional conditions is not enough. You want to give some additional detail if you will to what is the status of that.

When we talk about review of systems and we’ve talked in the previous podcast about the complexity if you will or the necessity of redoing a complete review of systems. And certainly if a patient comes in with a problem focus type of history, “I injured my elbow,” I would expect that there is an assessment or review of their extremities.

And generally what we see is it’s either a minimal review of the systems or completely absent within the note. Now, again that’s not to say that that review wasn’t performed. It’s the question of why did it make it to the actual documentation.

And then lastly around history has to do with the past family social history and things like that. And I think it’s the language that’s used. If you think about evaluating past medical history, family history, oftentimes you’ll see a notation from a provider that says, “Non-contributory.”

Generally with the arrow covering all questions, one response and the first question is “What exactly do you mean by that? What was the intent of that statement?” And I think the easy takeaway is non-contributory is probably not sufficient, especially with someone that has co-morbidities. You want to understand what the relationship is. Is there a family member with surgical histories, social histories and things like that?

So you want to start building your picture, building your puzzle and start putting these pieces together. So those are some of the things that we see around history.

Michael: So moving along to examination, can you discuss some of the common mistakes associated with that area?

Cyndy: Sure. I think some important points as far as documentation when you talk about the exams, specific abnormal or relevant negative findings of the exam of the affected or symptomatic body area should be documented. And what I mean by that is simply noting abnormal without any additional elaboration or documentation is not Any abnormal or unexpected findings of an area that was asymptomatic. Example, I came in due to an injury to my elbow. However, in reviewing the limited review of systems, you also note that there’s significant range of motion issues with my other arm. Again, it’s not necessarily what I came in for today, however it is still an unexpected or not normal finding. So again, that information, that piece of data should also be added to the record.

In addition, a brief statement or a notation indicating negative or normal is okay if you’re documenting the findings related to an unaffected area. Example is going back to our elbow issue, other extremities are normal, meaning that there is nothing else significant there.

One, I guess, word of caution with that in writing a negative or normal, it is not necessarily appropriate to label an entire organ system as negative. You should provide a little bit more detail. Certainly, looking when you’re doing a multi system exam, one broad label if you will of normal or negative is probably not supporting the documentation. You should provide that additional detail.

Again, going back, I think documentation as a whole as it relates to exams, generally we see a lot of “lack of,” lack of information. A lot of this and we actually will talk about this in the near future, a lot of this documentation in what might be missing or not available could be – not necessarily is, but could be attributed to the electronic health records where there has been the development of templates and dropdown screens and things like that, which can limit the additional free text ability if you will to provide the additional information. Sometimes it’s simply not documenting that an exam was even performed, just moving right past it.

I think another area that we see some challenges is the mixing of body areas or organs basically to meet a specific E and M level again, if you’re looking for that comprehensive level, the more complex. And there is a multitude of organ systems that were reviewed when in fact perhaps the patient only came in complaining about a respiratory infection. It’s not necessarily more documentation means a higher level. If it doesn’t fit, why the patient came in, in the first place?

And then lastly we talk a lot about the electronic records or templates or checkboxes. A lot of organizations prior to the electronic health record would have templates where you can go down and do a review systems and it’s “Check yes, check no. Check yes, check no.”

However, checking an abnormal box and not elaborating exactly what you mean – normal, abnormal, you check abnormal – not elaborating on that is not going to benefit as far as the coding and reimbursement. So I think those are some challenges we see around examination.

Michael: So what do you see around medical decision-making?

Cyndy: Some of the challenges with medical decision making have to do on the severity and the number of the problems. You cannot base your sole reason for medical decision-making on the severity or just the number. This patient has 10 co-morbidities. By virtue of a high number doesn’t necessarily get you a higher level E and M. You have to include all of the components for each of the diagnoses. So it’s not just simply a list.

Another area that could be a challenge is the orders. Orders that are not documented or listed without any correlation or relationship to the problem or the plan is not helpful. The orders need to reflect why something is being ordered, what the thinking is behind it, what the outcome is that you’re concerned about, what the risk perhaps is that you’re concerned about.

And I think it’s important to consider this. An order without a reason would be considered or could be considered medically unnecessary. So when you think about an order for a reason, “Order this for that. Order this for that,” it certainly assists if you will in the documentation to support exactly what the provider is thinking.

Another area that we look at is the diagnosis. And what I mean by that is lack of specificity in the document from the physician. We see the diagnosis coding on the claim that is actually more specific than the actual documentation. So it really needs to go the other way. The documentation is there to support a diagnosis and then this case, this claim is coded based on that documentation.

Another area in fact related to documentation is procedures that are performed in the office. We do see a lot of – I want to say lack of documentation or insufficient documentation provided for procedures that were performed in the office setting. Patient comes in, they have an office-based procedure and there’s no documentation, whatsoever. We would not have even known the procedure was performed.

I think lastly, which has to do again with documentation, is the actual authentication. The author, the provider who’s actually performing the exam, the documentation is not signed. It sounds hard to believe, but we do a see a lot of that, lack of authentication.

Michael:  And then in all of this, legibility is still a common concern?

Cyndy: I’m afraid so. Legibility until we go completely away from a paper record will continue to be an issue. There are some organizations through the years who have, in order to facilitate or try to lessen the number of eligible entries even around physician signatures, will assign a number to the physician. So the physician, you may not be able to read a signature, but you may see provider number one, two, three. Or I may not know who the signature is, but I do have a means to look up who provider one, two, three is.

Some organizations have gone on to stamps in addition to the actual signature so that they go together. But yes, legibility has been and probably will continue to be for some time a documentation issue.

Michael: And date and time documentation, that can actually impact compliance as well, correct?

Cyndy: Absolutely. Dating and timing have long been challenges. Again, the electronic record with its automatic timestamps certainly does help. In an office setting, you may or may not have that option as well as in a hospital. But the dating and the timing of both the treatment and/or the signatures if for some reason they’re different is imperative because again you’re showing the flow, the chronological flow of the care for this patient.

Michael:  So Cyndy, you did a great job over the last several minutes laying out lots of different common mistakes that can occur. How do these mistakes affect accurate physician documentation and coding?

Cyndy: These mistakes will impact the ability of an organization or a provider to prepare and submit a clean claim, an accurate concise claim for reimbursement. If the information is not available, if for whatever reason, it’s just not sufficient, what happens is the claim is then returned to provider and you literally go through the process again. So there could be a revenue issue, a reimbursement issue. If you have to keep resubmitting claims.

So again, there could be delay on adjudicating acclaim, which could have an effect on your revenue flow. You could have an increased number of denials. We all know that increased number of denials could be a red flag. So those are probably the top two that are significant.

Michael: I want to ask you to just provide some parting advice for our audience. What do you think they should know about handling these physician documentation and coding challenges?

Cyndy: I think the most important would be educate, educate, educate. There probably can never be enough education. We assume that physicians have all of the education knowledge based on their training to document. And I think what’s important when we think about education is we’re not questioning the medical decision-making, what went into making that clinical decision.

But when we educate, what we’re talking about is “Help me understand what we could do differently to capture everything in your head if you will so that we can paint a clear concise picture of this patient, what your concerns are, what contributed to those concerns, how you developed your plan of care. What are some of the things you’re worried about with this patient?”

It’s really to establish a win-win. From an education standpoint and auditing standpoint, we’re not necessarily looking at, “Oh, this physician does it well. This physician doesn’t do it well.” The idea of education is “To help me help you. I want to submit a clean claim, turn it around quickly, get the payment to turn that revenue over.” And I need to be able to work with the physicians to develop whatever tools are necessary to gather all of that information the first time.

So I think the takeaway would be constant education. Auditing, if there are physicians that are doing well, I think it’s important to tell them that they’re doing well. If there are physicians that are challenged, I say go back and educate again and again and again because again, it will be a win-win for everyone.

Michael: Cyndy, thanks for spending some time with us and illuminating the common mistakes associated with physician documentation.

Cyndy:  Thanks, Mike.

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