Physician Documentation Is Still Lacking; Inadequate Coding Raises Medicare Compliance Risks

January 4, 2009

Reprinted from REPORT ON MEDICARE COMPLIANCE, one of the nation’s leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

Even with the risk of Medicare audits and the potential loss of money from undercoding, physician documentation improvements have fallen short of expectations, experts say. Inadequate documentation is not uncommon — whether it’s too little overall or not sufficiently descriptive of the patient’s problem. There are, however, key points to hammer home to physicians that may eventually have an impact, especially if they start to feel the heat from recovery audit contractors and Medicaid integrity contractors.

Physicians (and other clinicians) don’t usually bang down the door to attend coding and documentation training. Their focus is direct patient care, and they may not see a connection to compliance. But Lynn Myers, M.D., vice president of coding, compliance and education at Medical Edge Healthcare Group, a Dallas-based physician management organization, was surprised by the lack of follow-up questions after she did a mini-review of a group of physicians’ medical records. “I am amazed and stunned that my e-mail is not on fire with questions from them,” she says.

It may be an uphill battle, but there are ways to get through. One key message is that medical records must be “accurate, adequate and clinically useful.” Five words won’t capture the diagnostic and treatment plan for a 68-year-old woman with three chronic conditions who takes four medications.

Myers explains to physicians that auditors are not mind readers, physicians or nurses and may not even have clinical experience (unless it’s a medical review). They are professionals and certified coders, but they can’t make assumptions about the medical record. “They can’t look at your charts and tell how you arrived at your treatment plan if there are five words. Providers should ‘think in ink,'” says Myers, who is a family practice physician.

She also conveys to physicians that medical records must tell a complete story in the absence of the treating physicians. What if the patient is transferred to another facility or the treating physician leaves Medical Edge? As she tells her colleagues, “the new physician needs to pick up the chart and know what you were thinking – they need to be able to say ‘Oh, I see why he changed the patient from that med to that med,'” she says.

And for the younger physicians who came of professional age steeped in compliance and enforcement and who might be tempted to go overboard in the other direction, Myers conveys they don’t have to write dissertations about all of a patient’s body systems. “It doesn’t have to be prolific,” she tells the physicians. “Don’t write flowery sentences. Hit the high points. Write adequate information that allows someone else to follow what you are doing. It’s not the most verbose person who gets a good audit. It’s the person who has the best information in their charts.” (Myers often uses the term “physicians,” but she audits and educates other clinicians, including nurse practitioners and physician assistants.)

Established Patients Often Underdocumented

One of the major physician documentation challenges in medicine is eliciting all the documentation requirements for an established patient. “Established patients are most often underdocumented,” she explains. The reason: Doctors remember so much about a patient’s history when they see a face or name (e.g., that patient has high blood pressure, smokes, is at risk for diabetes). “Because it’s in the doctor’s head, she doesn’t feel like she has to write it down,” Myers says. The documentation with established patients tends to focus on medical decision making — new tests ordered, prescriptions refilled. “But they forget the auditor doesn’t have that knowledge,” she says. It isn’t necessary for the physician to recreate the entire history, but she should update what’s new. With electronic medical records, it’s a no-brainer to bring forward past history into the new visit. New items are date stamped so the auditor will know what has changed.

Documentation of specialty consultations is another problem area, Myers says. “Often specialists will write a consultation note in their internal medical record that contains very little information. Sometimes it’s hard to tell why the patient was there,” she explains. Yet the specialist’s letter back to the ordering physician “is quite informative,” she says. “The specialists want to give good feedback so the primary care physician will know what’s going on” and because they appreciate the referral. Regardless of the content of the response letter, the consultant’s internal record must contain the required elements of documentation in order to qualify for a level of service.

To help physicians improve documentation, Myers holds 90-minute coding and documentation compliance training sessions with every physician who joins Medical Edge. She customizes the training to her audience (e.g., hospitalist, pediatrician, primary care physician) and brings in a billing department representative to answer the scores of billing questions that typically arise during the sessions.

One common question is whether physicians may charge for smoking cessation. The answer, Myers says, is that physicians may get paid for smoking cessation as a separate event if it’s well documented, depending on the payer. But telling a patient to just say no is not the same as counseling for smoking cessation, and that must be clear in the patient’s chart. “The [physician] evaluates the patient for their smoking-related condition, then must code the visit for that condition, such as chronic obstructive pulmonary disease, and then add on the smoking cessation code for additional reimbursement,” Myers says. “If it is a deliberate event and not just a ‘you know you need to quit’ type statement, it’s worthy of separate reimbursement.”

When billing commercial payers, physicians may be able to bill a higher-level evaluation and management (E/M) service if they document the time spent with the patient on smoking cessation in addition to the time spent evaluating and managing the condition that occasioned the visit, Myers says. Medicare will pay for two smoking-cessation efforts a year. If the smoking-cessation discussion lasts three minutes or less, Medicare considers that part of the E/M for that date of service, according to the 2008 CPT professional codebook. But if the discussion lasts between three and 10 minutes, the add-on code 99406 may be applied, Myers explains. “The physician must document in the note the patient’s disease that is affected by smoking or the adverse health effects on the patient caused by smoking and the context in which the counseling was provided,” she says. For more than 10 minutes of counseling, the 99407 is applied.

Time spent in the visit must be documented clearly.

Formal and Informal Audits Conducted

Medical Edge conducts several different kinds of audits. “I do documentation and coding audits that are informal,” Myers says. She takes a stack of medical records and looks for the key components and whether the physicians used proper codes for items that were evaluated during the patient’s visit. “I am looking at them from the doctor’s point of view, and I give them feedback,” she says. These are audits of E/M services and add-on codes.

One example is an add-on code for prolonged services reported in addition to an E/M code, Myers says. Suppose the patient is at the physician’s office for a sick visit and becomes short of breath and almost passes out and the doctor calls 911. The patient is kept in the physician’s “urgent” bed and tended by the physician until paramedics arrive. “The physician can report the E/M code for the sick visit plus an add-on code for the additional face-to-face care (as long as the additional care totaled 30 minutes beyond the threshold time for the E/M that was reported),” says Myers.

Another example, Myers says, is when the provider evaluates a patient for a cough and determines the patient has pneumonia. The provider prescribes medication and gives expectorant management for the condition. The patient has additional questions because she is a jogger, the mother of an infant child and the caregiver for a family member who is on chemotherapy. The provider ends up spending 32 additional minutes discussing issues related to the diagnosis and counseling the patient. The provider spends a total of 47 minutes with the patient and may report 99213 (typical time = 15 minutes) for the pneumonia, plus the add-on code 99054 (30+ additional minutes) for the additional face-to-face time (15 + 32 = 47). This time must be documented clearly in the record, Myers says.

Medical Edge also has audit tools for more formal audits. “We are developing a program to audit every physician, every year,” says Myers, a tall order since more than 500 physicians are affiliated with Medical Edge. The goal is to benchmark so “each physician can see if his or her audit score has improved. It gives them an idea of where they stand and where we would like them to be.”

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