February 11, 2022 | Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content, innoviHealth
How have you felt when you embarked upon an audit, expecting to find certain basic standards of documentation to be present, but instead found them missing? Do you pull out your favorite red pen, grab a cup of your favorite caffeinated beverage or a snack and ready yourself for the disasters you may find? If we asked this question during a conference session, I am certain the conversation would be a lively one with everyone having a story to contribute. Documentation and how it is organized plays a vital role in auditing successes and failures.
Many of the basics of a medical report are often found missing or inadequately documented, such as:
- Patient name vs nicknames
- Appropriate template use
- Formatting to capture all billable services
- Editing out template prompts
- Linking questionnaires, lab/imaging orders, and prescriptions to the current note
- Signing and closing the document
- Editing voice-to-text errors
And this list could easily go on and on.
Jumping into an audit often makes me feel like I get a sneak peek into the hectic or calm thought processes of the documenting healthcare provider. This can either be an enlightening experience or one that makes you question your career choice.
Order or Chaos
Everyone is trying to maximize their time at work but unfortunately, we find we are unable to accomplish as much as expected, which may lead to cutting some corners. Providers are no different, but cutting corners in documentation or even just giving a brief summary of the encounter can lead to significant losses.
While it may take a little extra time to create a template or format a document, doing so often pays off in unimaginable ways. It is apparent to anyone who creates, codes, or audits the medical record how integral it has become to so many major decision making trees. Provider notes have evolved from a simple form of provider-to-provider communication to a document that is used in so many different ways, the following being just an example:
- Risk adjustment scoring for plan funding
- Preauthorization for medical services
- Portable record for patient’s who change providers or want to review their records
- HIPAA protected patient information
- Legal document for many different issues
- Source document for coding, compliance, and research
Let’s Talk Formatting
While templates can save a provider time by creating an organized outline of the required documentation fields within a note, it can especially help coders and auditors locate, code, and give appropriate credit for important data, procedures, orders, and referrals.
If your role as an auditor is to support the provider in their documentation and coding programs, then consideration of how their individual templates are created and formatted should be part of that process. Many providers work directly with administration or the salesforce of the EHR software vendor to create templates, never involving a coder or compliance officer in the process. This almost always leads to significant errors that later have to be addressed, and with some software vendors can be a very lengthy and difficult process. Because software is often designed to help providers document quickly, it often is misses the mark when it comes to formatting to capture key elements that can have a serious impact on provider reimbursement.
At the very least, the process for determining formatting of templates should include the vendor, provider, and compliance personnel who have coding/auditing experience. They have the ability to recognize details required for certain types of services a provider may perform and how proper formatting will facilitate capturing needed details to meet the criteria for specific services.
For example, providers who often perform minor procedures during E/M encounters will need to justify any use of modifier 25 for E/M performed the same date as a procedure. Formatting these notes to maximize data capture and the procedure details is vital. The same goes for providers who perform an E/M service during the same encounter as a preventive service. Review templates for these providers to determine whether the template has been formatted with the proper section headers to support each individual service.
With the 2021 changes to E/M (99202-99215), we are all busy trying to identify the best way to document the details of any data that is ordered or reviewed and distinguish it from external data being reviewed. Also, formatting to capture diagnoses that were monitored, evaluated, assessed, or treated during the encounter from those found on the patient’s “problem list” is another important issue. Proper formatting can facilitate scoring of data elements and diagnoses to support an appropriate level of E/M service.
Include Formatting Recommendations in the Audit Report
Auditors should include feedback to their providers on document formatting, specifically addressing those areas that make their coding vulnerable, such as the decision to perform a minor procedure during an E/M encounter visit. Ensure the documentation not only is formatted to capture the decision was made during the encounter to perform the procedure, but the procedure itself is formatted in such as way that it is easy to identify the procedure details so proper reporting of the procedure can take place. Consider formatting all procedures to a separate line with an appropriate title, PROCEDURE:, to ensure they are easily identified and contain all the details to allow for proper code selection.
Data ordered and/or reviewed during an E/M encounter is another vulnerable documentation point that should be clearly formatted to show who ordered it, when it was performed, and if reviewed during the current encounter, what the provider’s professional opinion of the results were. This allows for less confusion in trying to identify who gets credit when scoring medical decision making.
Another issue often seen in Emergency Department notes are laceration or wound repairs performed by a provider other than the E.D. physician. Often the details of the wound (i.e., length, severity, anatomic site) are well documented in the E.D. physician’s note but the provider performing the repair uses a template without capturing these key details of length, location, and severity. The coder may pull the information from the E.D. report but if an audit of the procedure note iself was performed, it would not contain the information required to support the service.
Formatting is a basic or foundation principle in documentation and is impactful to reimbursement. Take the time to identify and address formatting issues as you work to improve auditing outcomes for your provider organizations. Additionally, if you work with any computer-assisted coding products, formatting will quickly become your ally in that proper formatting and sectioning will allow for more precise code recommendations. No matter how you look at it, addressing formatting basics helps resolve missed revenue and ensure criteria has been met to support the services reported.