Coding & Clinical DocumentationPatty Harper

RHIA, AHIMA-AppICD-10CM/PCS Trainer,

CHTS-IM, CHTS-PW, CEOInQuiseek

The encounter, the clinical documentation and the claim all should represent the same picture. Subtle differences can create big issues!

Elements of a Typical Clinic

Note

Element Part of Note

Nature SOAP

Chief Compliant History Subjective S

HPI History Subjective S

Review of Systems History Subjective S

Problem List History Objective --------

PFSH History Subjective S

Examination Exam Objective O

Lab Results/Diagnostics Exam Objective O

Diagnosis Assignment MDM Professional Judgement

A

Treatment MDM Professional Judgement

P

Medication Reconciliation

History Objective or Subjective --------

Chief Complain

The Chief Complaint is the reason that the patient gives for coming into the clinic. However, this may not be the “real” reason for the visit. The provider may change or reword the chief complaint upon determining the true nature of the presenting problem(s).

▪ Be careful of systems which populate the chief complaint from the appointment reason.

▪Educate providers that they can change the chief complaint.

▪The CC is the beginning of the story. We don’t want a chief complaint and a primary diagnosis that aren’t logically connected.

Other Problems with Chief Complaints

The Chief Complaint also helps establish medical necessity and if an RHC encounter occurred.

Avoid or Clarify

▪Follow-up: Use the condition requiring follow-up or “follow-up for hypertension” (condition).

▪Annual exam or check-up: Medicare never covers a routine examination. Wellness visits are different. List conditions being followed.

▪Lab Results: If lab results are abnormal and require an additional service, report the condition.

▪Status of Chronic Conditions not documented as part of History. An auditor may not look all the way down to the Plan section of the note.

History of Present Illness

History of Present Illness is obtained by interviewing the patient about the onset, severity, duration, timing, associated signs and symptoms, context, and modifying conditions related to the Chief Complaint.

Although this information is often obtained by nursing staff, it is the provider’s responsibility to verify the HPI and to interview the patient further. The provider should be collecting HPI.

▪Often the provider interviews the patient but doesn’t validate or document the additional HPI.

▪If the Chief Compliant changes, so does the HPI. More interviewing is necessary.

Review of Systems

The ROS is the only part of the History section that can be recorded by nursing or collected directly by from the patient. It is subjective from the patient’s perspective.

Many clinics are using intake forms or tablets to collect CC, HPI and ROS from the patient. Many collect it but providers don’t review it.

Patients may list symptoms which are never addressed or added into the clinical documentation as being pertinent to the problem or indicative of another problem.

No ROS at all is a common audit finding.

Personal, Family and Social History

All of the History section of the note should be PERTINENT to the chief complaint/reason for the visit.

It is not necessary to obtain personal medical history/surgical history from the patient for conditions that happened years ago which have been resolved and are unrelated to today’s problem.

It is not necessarily pertinent that I had my tonsils out when I was 5 if the reason for my visit is a sprained ankle. The fact that I had knee surgery last year might be pertinent.

Be efficient in workflow by making data collection relative to the visit.

Physical Examination

▪Body systems identified in the HPI or ROS are marked as “wnl” or negative in the note.

▪Exam components are cloned from patient to patient or from encounter to encounter. The exam documentation looks the same for all patients or for all of a patient’s visits.

▪System marked as remarkable but no detail given about abnormal finding.

▪ 4 x 4 system documentation is missing from higher level E & M visits.

▪Discrepancies in laterality, gender, location of pain, presence of pain, site, etc.

▪Body systems and Body areas mixed-up.

▪Exam not documented at all. Free text is better than nothing.

Point-of-care Test Results

not documented

▪Point-of-care lab tests performed but not documented in EHR or Charge Capture.

▪Confusion over who is will document when CLIA labs are performed by nursing based on protocols. Nursing sometime cannot do this based on EHR settings.

▪Tests performed &used in assessment but not documented.

▪Diagnosis not supported by test results.

Procedure Coding and

Documentation

▪ A common audit finding is the absence of a procedure note when an in-office procedure is performed. Example: destruction of skin lesion, laceration repair, joint injection, IUD insertion, I & D, etc.

▪No details of procedure in note at all, but charge drops. Free text is better than nothing.

▪Make sure EHR can capture a procedure note.

▪Obtain procedural consent for any invasive procedure.

▪Nursing documentation for injections, immunizations, bandage change even if not a billable encounter.

Diagnosis Assignment

and Sequencing

▪ The primary diagnosis is the one most related to the Chief Complaint.

▪Diagnosis not logical in respect to clinical documentation.

▪Acute conditions are sequenced before chronic conditions.

▪ If multiple problems are equally addressed, either may be the primary diagnosis.

▪Symptoms which are integral to the definitive diagnosis should not be listed; some EHRs require this if the treatment includes separate plans by symptom. Doing this can artificially the MDM and E & M level.

▪Diagnoses on the problem list should not be pulled into assessment unless they are addressed during this visit or were considered in the treatment options. Some EHRs pull over the problem list automatically.

Diagnosis Assignment

and Sequencing

▪Symptoms are coded when there is not definitive outpatient diagnosis.

▪Outpatient coding guidelines do not support differential diagnoses or rule-out diagnoses. Inpatient coding guidelines do.

▪For risk adjusted/HCC coding, only report the diagnoses addressed during the visit or considered this visit. Do not report all unless all are addressed. All chronic should be addressed sometime in the calendar year.

▪Diagnosis assignment should be as specific as the clinical documentation. The use of unspecified codes is only permitted when the clinical documentation does not support a more specific code assignment. Provider often see truncate descriptions or have memorized general codes.

Wellness Visits and Preventive Services

Medicare, Medicaid and other Payers have specific components of wellness visits and preventive services. Providers need to be aware of these. Customize templates to help guide documentation. Do not report a service unless all elements were performed.

This includes Medicare IPPE and AWV services.

Do not report an annual check-up or follow visit for chronic conditions as an AWV.

CPT® and HCPCS® are different between payers.

Preventive service may be restricted by frequency, age, or gender.

Nursing Home and SNF Visits

Documentation for RHC encounters billed for nursing home, SNF, and other location visits should fully support the level of service provided.

Clinical documentation should be in the RHC EHR and not just in the nursing home chart.

Use tablets for documentation or have note templates available at the facility for the providers to use.

Do not use “gang” billing. Every service should not occur on the same day of the month.

Providers are doing the work but not getting it down on “paper”

▪Providers are usually doing the work—mentally, physically. The medical decision-making is being performed.

▪It is not, however, being documented for one reason or the other.

▪RHC providers are keenly familiar with their patients and they often connect the dots and formulate assessments and treatments without documenting their “work”. It’s automatic.

▪We need to be reminded that an auditor who neither knows your patient or your provider will try to make heads and tails out of a note years after it was written. That is the concern.

Remember that Providers are not Coders and Coders are not providers.

Providers are trained to assess and treat patients. The process of making a diagnosis is very different than the process of assigning a diagnosis or procedure code. Code assignment is not intuitive to providers. Making a diagnosis or developing a treatment plan is.

EHR Implementation has given the provider more direct responsibility in the coding function.

Providers must be given some help in learning coding guidelines.

High volume clinics are employing coders as revenue-cycle team members.

Charges Dropped but

not documented or vice versa

For clinics on paper or hybrid systems, sometimes we see charges drop on the claim that are not supported by clinical documentation. Labs, in-office procedures, other diagnostics.

Sometimes services are documented and not charged.

Clinical workflow, administrative checks and balances and correct bill formatting within the system are essential.

Signatures & Open Notes

▪Open, unsigned notes

▪Delay in signing charts leads to documentation discrepancies and lack of detail. 40-60 days?

▪For PBRHCs, medical staff rules and regs should govern completion of notes. PBRHC providers are required to be governed by the hospital medical staff. (42 cfr 413.65)

▪Independent clinics should have clearly understood expectations for timely signatures.

▪With optimal EHR use, notes should be signed within 48 hours unless waiting for reference lab results.

EHR Implementation

We still have a love/hate relationship.

The pros out weight the cons.

Handwritten notes and hybrid notes are hard to audit.

Involve providers in product selection, implementation and training.

Don’t succumb to hiring scribes unless absolutely necessary.

Compensation should be tied to EHR/HIT adoption.

EHR Training &

Optimization

EHR design and set-up is necessary for good documentation and provider buy-in.

Staff and Provider training is absolutely necessary.

EHR adoption should be part of the provider’s employment or compensation agreement.

Customization is worth the added cost.

Be prudent when selecting which fields and screens are mandatory to complete. Optimize workflow as well as ease of documentation.

Focus on what can be done and not what cannot be done in your system.

Discourage work-arounds if they compromise the quality of documentation or quality reporting.

Patients Over Paperwork

CMS has launched a “Patients Over Paperwork” initiative which seeks to unburden providers with unnecessary paperwork.

Provider should not respond to this initiative by reducing the quality of clinical documentation. Patient care is important. And other reporting requirements depend on good documentation.

Audit and Retrain as part

of your Compliance

Plan

Perform internal audits for overall quality of documentation and record completeness.

Perform focused audits on new providers or for specific problem areas or suspected problem areas.

Benchmark providers E & M levels by MGMA or CMS standards. Identify trends which are outside the bell curve.

Provide provider-specific education to improve quality of documentation and code assignments.

Get outside help if needed.

Have checks and balances in place. Do not pay wRVU bonuses without chart auditing. Reconsider wRVU models for RHCs.

The encounter, the clinical documentation and the claim all should represent the same picture. Subtle differences can create big issues!

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Patty Harper, RHIA, CHTS-IM, CHTS-PW

pharper@inquiseek.com

www.inquiseek.com