October 7, 2022 | By J. Paul Spencer, CPC, COC
Early September marked my 33rd year on the administrative side of healthcare. This followed my 56th birthday in April when I officially entered the realm of “pushing 60”.
Once you get to be my age, the reaction to my opinion falls into one of two camps, best defined briefly as either “let’s tap him for some wisdom” or “tell him to take his abacus and get lost”. The good thing about NAMAS compliance tips is that someone is asking for the former.
Today, I want to focus my aging attention on medical record documentation, specifically, the portions called History and Examination. We currently find ourselves in an interesting gap of time. It has now been 21 months since outpatient documentation standards were officially reoriented to the assessment and plan, but we are also 2 ½ months away from these same standards being applied to other places of service, most notably the inpatient space.
There is a portion of me that can’t believe that I need to type this next sentence, but here we are. You still need to document a medically appropriate History and Examination. I type this because I am still hearing anecdotal evidence that this thought process has infected some medical practices out there.
Providers, and the auditors who love them, exist in different worlds. The auditor wants documentation that supports a level of service for purposes of billing compliance. While a provider doesn’t object to that goal, there is still the need to create a problem-oriented medical record, as designed in 1969 (when I was 3) by Dr. Larry Weed, the Father of the SOAP note.
In the words of Dr. Weed, a medical record must provide:
- A clear definition of the problem
- Data to support the definition
- What is being done to try to solve it, and
- Must be thorough, reliable, analytically sound and efficient
It was with these principles in mind that the SOAP note was developed.
I fully understand that in the new paradigm of the electronic medical record, combined with the lingering hangover of the ’95 and ’97 guidelines, the SOAP note has devolved into a deluge of information, reordered and reorganized for the twin convenience of the provider’s time and audit guidelines. Having said that, unless the encounter is documented as counseling only, there must be a medically appropriate history and a medically appropriate examination documented as part of the evaluation and management service.
This point is most important to make at this tenuous time when inpatient services are about to adopt the outpatient E/M model. There is a tendency within inpatient documentation for information to be carried forward through the entirety of a hospital stay, with minimal updating of information, and calling it a day, as far as subsequent hospital visits are concerned. This type of documentation needs attention sooner rather than later in the lead-up to 2023.
Consider for a moment the documentation of interval history, as it relates to the assessment and plan. It is common for chronic conditions to be managed along with acute conditions in the hospital setting. If a provider wants credit for the management of chronic conditions during an inpatient stay, reflecting on either the stability or the effect of a chronic condition on acute conditions will need to become a part of an interval history. This will show that these conditions were meaningfully assessed during the encounter.
“Thorough” and “efficient”, as defined over five decades ago by Dr. Weed, doesn’t mean a litany of endless reiterations. Each encounter, even in the inpatient setting, still must stand on its own as an independent assessment of the patient’s condition, which also follows Dr. Weed’s guidance.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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