excellence in medical documentation

Top Ten Medical Record Documentation and Coding Tips

1 FLORIDA MEDICAL CLINIC IPA PROVIDER “Improving Clinical Documentation”

Excellence in medical documentation reflects and creates excellence in medical care.

1. Avoid EHR shortcuts:

EHRs have simplified documentation and record tracking. Inaccurate Documentation increase risk for patient safety, quality of care, and compliance concerns.

EHRs allow physicians to “Copy and Paste” information from previous patients visit. o Although physicians may view this feature as a timesaver, progress notes are crucial for successfully

supporting the reasons for continued care. o Documentation shortcuts like “Copy-Paste” can create difficulty in supporting medical Condition.

Dictation Errors without Validation. o Verify validity of information on entry when possible. o Check for duplication and conflicts. o Control and limit automatic creation of information. o Monitor corrections and additions to the medical record.

Cloning, Copy/Paste Practice Problems: o “Copy and paste” to replicate information from a previous visit—a function that pulls in specific

identical data elements. o Automated insertion of previous or outdated information through EHR

When not modified to be patient-specific to the visit, may raise significant quality of care and compliance concerns—creating a potential for medical liability issues.

According to CMS Compliance every medical record for Date of Service should stand alone.



Common documentation risks that can result from cloning features include:

Be extra careful when you think you are "too busy."( Abnormal vital signs, Assessment, Diagnosis Codes, Medication)

Vital signs that never change from visit to visit. Documented and actual BMI does not mach. Documentation from another provider including their attestation statement. Identical verbiage used repeatedly (i.e., use of pronoun “he” instead of “she,”

Indication that patient has no pain when the documentation includes a record of pain) Any error made in prior visits will reflect same error in all Copied record. HPI remain same when Copy from prior visit and create contradiction with current Chief

complain for visit, and Assessment. Physical examination will contradict with final assessment of Diagnosis. Assessment does not match with rest of documentation. Sometime create contradiction

with other assessments.

Template Documentation : o Documentation templates can play an important role in improving the efficiency of data collection,

ensuring all relevant elements are collected in a structured format. However, these templates also have limitations:

o Templates may not exist for a specific problem or visit type. This issue can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient’s condition and services.

o Atypical patients may have multiple problems or extensive interventions that must be documented in detail.

o Templates designed to meet reimbursement criteria for Fee For Service (FFS) payments. Templates may also encourage over-documentation to meet reimbursement requirements FFS even when services are not medically necessary or are never delivered.



2. Be exact when Time is a factor: applies to (HPI) (Chief Complain)

Bad example: “20 year history of diabetes.”

“Prior MI 2 year ago.” Or “History of Acute MI 2 year ago.”

“Recently discharged from the hospital”

“Patient is here for hospital follow-up.”

“Visit for recent Hospital Discharge.” (Does this make sense?)

“3 month follow up”

“Patient here for Medication refill”

“Diagnosis A B C seeing Dr. XYZ.”

Good Example: “Patient was discharged from the hospital on 1/15/2015 after admission for Intestinal

obstruction, with Colostomy status”

“Patient is here for first follow up visit after Great Toes amputation (s/p Cellulitis followed by

Surgery) on 1/25/2015. Now present with second and fifth toe gangrene on right foot.”



“Patient with Diabetes Type II, since 1995 now with Complication”

“Previous Myocardial infarction, 04/15/2015. s/p CABG.”

“Discharge from St.Jose on 1/31/2015. For CHF and Atrial Fibrillation (New Episode on

1/29/2015).”

“Patient was discharged from ABC Medical Center on 2/25/2015 after inpatient admission for

acute myocardial infarction.”

“Patient was discharged from Medical Center one week ago after inpatient admission for

acute myocardial infarction.”

“Patient here for Chronic Disease (Diabetes / COPD / CHF) patient's treatment progresses,

symptoms start to disappear and assessed to plan effective care and treatment for the

continuation phase.”

“MD Specialist DOS:xx/xx/xxxx, assessment findings discussed with Diagnosis, and no

additional orders at this time.”

Patient here to discuss assessment from Dr T( Specialist / Psychiatrist) patient's treatment

progresses, symptoms start to disappear and assessed to plan effective care and treatment for

the continuation phase.”



3. Provide full diagnosis detail:

(Managed Care Providers gets reimbursed exclusively on the reporting of codes ICD-9-CM.)

(Fee For Service Providers gets reimbursed exclusively on the reporting of CPT E&M codes.)

Diagnosis coding guidelines require a strict literal interpretation to your medical record documentation.

Do include co-existing complications and co-morbidities that either require physician management or affect the physician’s management during office visit.

The following documentation tips can help ensure accurate medical coding and billing compliance for Medicare risk adjustment.

These tips are based on the…

1. Centers for Medicare & Medicaid Services’ (CMS’) requirements for Medicare Advantage plans. 2. Official ICD-9-CM Guidelines for Coding and Reporting. 3. American Hospital Association (AHA) Coding Clinic guidelines.



4. State the diagnosis to the highest level of specificity:

Document all conditions treated at least annually and more frequently as required by treatment guidelines.

Probable, suspected, questionable, rule out or working diagnoses cannot be reported to CMS as valid diagnoses in an outpatient record.

Clearly document how the reported condition was Monitored, Evaluated, Assessed/Addressed or Treated. ( M.E.A.T. )

Use appropriate descriptors to increase the specificity in documentation.

Describe each condition to the highest level of specificity in assessment. (i.e., with or without exacerbation, acute versus chronic, stages or types, controlled or uncontrolled, etc.).

Examples: o Diabetes mellitus (DM)

– Specify: - Type (type 1, type 2, secondary to − specify causal condition).

- Status of diabetes control (controlled or uncontrolled). - With or without complications or manifestations (fully describe each complication or manifestation separately too).

o If there are complications or manifestations of diabetes mellitus, you must clearly and directly link diabetes to those complications or manifestations using terms such as “with,” “due to,” “secondary to,” “associated with,” and “related to.”

o Document each and every complication of diabetes with the descriptor “diabetic,” as in “diabetes mellitus type II, controlled, with diabetic neuropathy.”

o Chronic kidney disease (CKD) – Specify stage I-V or end-stage renal disease (ESRD). Remember, even if lab values and/or the Glomerular filtration rate (GFR) are documented, the record must clearly specify the stage of CKD.



5. Create a clear relationship to the diagnosis (Causality):

Show a clear, causal relationship between any condition and its respective manifestation(s).

Use linking verbiage such as “due to,” “because of” or “related to” to establish this relationship. o The word “with” does not establish a cause-and-effect relationship except in the case of “diabetes

with neuropathy”

Coding guidelines prohibit making assumptions. If there is no clear causal link from one condition to the other, it cannot be coded as a manifestation of another disease. I.e. Diabetes and CKD does not translate into ‘Diabetes with Renal manifestation’ and ‘CKD due to DM’ unless stated specifically by physician.

6. Include all conditions related to health status:

Document all chronic diagnoses as often as they are assessed or treated.

Document all chronic diagnoses when they are a consideration in the patient’s care.

Frequently overlooked, but significant conditions include: Transplant status, Quadriplegia, Dialysis status, Current -Ostomies and other artificial opening, Amputation status, and Asymptomatic HIV infection.



7. Use “history of” only when appropriate:

Do not use the descriptor “history of” to describe a current or chronic condition that is still present, active or ongoing, under treatment. (CHF, COPD, A-Fib, Diabetes, Multiple Sclerosis, Parkinson’s Dis.)

Do not use the descriptor “history of” to describe a current condition that is in remission. Describe the condition as “Major Depression in remission.” “Drug Dependence in Remission.”

A patient with a history of prostate cancer that has been eradicated in the past presents to the office to monitor for recurrence. The assessment section should not state “prostate cancer,” but rather “history of prostate cancer.”(Applies to all Cancer – Use History of Cancer after clinical cure of cancer.)

A patient with a history of Stroke that has been treated inpatient hospital and now presents to the office – Always use “History of CVA with or without late effect of CVA", never document active CVA.

Per ICD-9-CM guidelines, the term “history of” means the patient no longer has the condition.

Avoid using the words “history of” to document a current condition. (I.e. Diabetes Mellitus.)

Examples: “History of congestive heart failure” may not be use to indicate compensated congestive heart failure. “History of Atrial fibrillation” may not be use to indicate Atrial fibrillation controlled by medication.

8. Abbreviations in Documentation:

Avoid the use of abbreviations in medical record documentation.

The initial notation of an abbreviation or acronym should be spelled out in full with the acronym in parentheses, such as “myocardial infarction (MI)”or “rheumatoid arthritis (RA).” The subsequent mention of the condition can be made using the acronym.

Use only standard abbreviations.

Do not create your own abbreviations.



9. Complete and legible documentation:

Documentation should be clear, concise, consistent, complete and legible.

Records should be legible to someone other than the provider and immediate office staff.

Chart auditors (Medicare) will not guess at what you are stating.

Caution when using record templates.

Do not use conflicting or contradictory statements or Diagnosis.

Examples: o Right hemiparesis due to prior cerebrovascular accident, but the neurologic review of systems

(ROS) and neurologic examination are noted as completely normal. o New diagnosis of Diabetes with Neurological complication and Polyneuropathy in Diabetes with

complete normal physical examination.

10. The chart problem list should be up to date and include:

Each condition and the start date.

The end dates if the condition no longer exists.

The reason why the patient is disable status (Medicare beneficiary and under 65 years). Current problem list is important so other providers can know the medical condition of your patient. Also serves as a reminder to address each condition at least once a year.



– Helpful Tips for Electronic health record (EHR) Documentation:

• Use templates only as prompts for documentation.

• Don’t copy block of text or notes from one patient to another.

• Make sure that information is separate and distinct for each patient at each visit.

• The provider should perform and document the history of the present illness (HPI), the exam, and the medical diagnosis and treatment plan.

• Update the “Current Problems” list at every visit. (Do not Copy All Problem list)

• Review and update the medication list with any changes for the patient.

• Make sure that Diagnosis and the ICD-9-CM codes are correct.

• The Chief Complaint must be in every note. Bad Examples Include: Annual Exam, Patient here for 6 month f/u.

Do you have other tips to help with improving clinical documentation?

Please tell us about them.

Thank you, Achyut Shobhashana, MRA Auditor/Analyst Florida Medical Clinic, PA [email protected] Office: 352-458-3423 Office: (813) 712-1645 Ext 83423



Common Errors / Inadequate Documentation in in EHR. ICD-9 Description Inadequate

Documentation in EHR. Missing words(s) during Assessment Dictation/Documentation.

Diabetes, Type II, uncontrolled Diabetes, poor control Uncontrolled

Diabetes with neurological manifestations

Diabetes Peripheral neuropathy

Diabetic peripheral neuropathy or diabetes with peripheral neuropathy or peripheral neuropathy due to diabetes

Diabetes with renal manifestations and CKD

Diabetes CKD

Diabetic CKD, diabetes with CKD, CKD due to diabetes

CKD Stage___ I, II, III, IV ESRD ( On Dialysis)

CKD Renal Failure

Specify stage of CKD as I-V, ESRD, or ESRD On Dialysis.

Benign Hypertension High Blood pressure , HTN

Benign hypertension or use 401.9 hypertension unspecified

Hypertension BP 137/92 Hypertension or High Blood pressure without HTN

Major Depressive Disorder Chronic Depression Major , episode or remission

Acute Bronchitis/ Chronic Bronchitis Acute or Chronic

Obstructive chronic bronchitis COPD Obstructive Chronic bronchitis

Chronic Obstructive asthma Asthma Chronic obstructive asthma or Asthma with COPD

Bacterial Pneumonia Pneumonia Bacterial ‘specify infectious organism if known ‘

Hyperlipidemia / Hypercholesterolemia

High lipids/Cholesterol Hyperlipidemia or Hypercholesterolemia

Atrial Arrhythmia/Atrial Fibrillation Arrhythmia (unspecified) Atrial Arrhythmia / Atrial Fibrillation



ICD-9 Description Inadequate Document Missing words(s) during Documentation. Atherosclerosis of the extremities PVD Atherosclerotic of specific vessels

Arteriosclerosis of ( Lower Limb )

Phlebitis and Thrombophlebitis, deep vein, leg

DVT Phlebitis , Thrombophlebitis or use 453.4 DVT NOS

Complete heart block Heart block Complete (or third degree)

Congestive Heart Failure, uns Systolic, Diastolic, or Combined Heart Failure

Heart Failure LV dysfunction Diastolic dysfunction

Congestive or Specify Systolic / Diastolic / Combind Congestive Heart failure

Seizure Disorder Seizures Convulsions

Disorder or use 780.39 seizures NOS

Alzheimer’s Dementia Dementia Alzheimer’s Dementia or Senile Dementia

Hemiplegia due to old CVA Weakness after CVA Hemiplegia or hemiparesis ,as Late effects of CVA

Chronic hepatitis ( Viral or Non Viral)

Hepatitis Chronic Hepatitis, specific type of Hepatitis

Chronic Viral hepatitis ( B , C ) Hepatitis Chronic Viral hepatitis *specify type if known (i.e. Chronic Hepatitis C, B)

Pathological Fracture Fracture Pathological Compression Fracture or/ Osteoporotic Compression Fracture

Metastatic Cancer by organ/body site Secondary Neoplasm by site

Ex. Lung cancer with metastasis

State the organ or site of metastasis ‘ Primary Lung Cancer, Metastasis to Bone and Liver’

Refractory Anemia Anemia Specific type of Anemia , e.g. 284.89 Aplastic anemia, 283.1x - hemolytic anemia

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