September 25, 2019
Documentation in every setting begins and ends with the physician/advanced practitioner. It is not the quantity but the quality of the documentation that counts. Documentation is supported in the detail.
When I work with physicians on clinical documentation, the question that always comes up is: “What do I need to document to support the CPT code I bill?”
The rule of thumb is to tell the story. Make sure your template in the electronic health record covers the elements you need to evaluate and treat your patient.
The first important piece of the documentation is the chief complaint. Why is the patient being seen? Documentation should paint a picture of the patient’s condition. The chief complaint will drive the entire patient encounter. It is important to document a chief complaint for all patient encounters whether in the office/clinic or hospital.
For the initial encounter, it is important to provide more detail, such as the history of the present illness including the location of the problem, how long the condition has been going on, the severity or quality of the condition, and any associated signs/symptoms. Also include any pertinent review of systems, past medical, family and/or social history.
If the patient is unable to provide this information, a family member, or previous medical records, may be able to fill in the gaps.
The practitioner should always document an examination relative to the patient’s condition. Any laboratory and diagnostic testing, bedside or office procedures, and other activities should be included in detail. Any treatment discussion with family members or caregivers should be documented. The assessment should outline all conditions managed, any comorbidities that affect the patient’s care, and the status of the patient’s condition.
Subsequent encounters should also contain a chief complaint, the status of the patient’s condition, a focused examination, tests ordered, procedures performed other activities, and patient and family discussions. The assessment should always contain the status of the patient’s condition (eg, improving, worsening, failing to change) along with comorbidities that affect the patient’s care.
For both the initial and all subsequent encounters, the plan of care should reflect treatment decisions and the medical necessity for the encounter to support the level of service provided. The term “continue same plan” does not tell the story. Any plan of care should be restated or summarized for every visit after the initial encounter. Remember, documentation should tell the story to support the service billed.
Here are 5 tips for telling the story details:
Tip 1: Document a clinically relevant history, including an HPI, review of systems and past medical, family and/or social history related to the reason for the visit. Make sure the reason for the visit is specific.
Tip 2: Perform and document an examination that is relevant to the affected systems and body areas. Don’t just document a comprehensive examination to get to a higher E/M level.
Tip 3: Make certain every patient encounter is unique for the patient. Don’t just document the same history and examination for every patient. When you do, it gives the perception of cloning.
Tip 4: In the assessment and plan of care, list all conditions managed or that affect the management of the patient, such as diabetes, HTN, etc. Make certain your documentation states that the condition(s) is/are improving, worsening, stable, failing to change, etc. This can affect the medical decision-making element or complexity of the patient. This also validates medical necessity for the condition(s) treated.
Tip 5: Have a documentation review (audit) performed at a minimum on an annual basis. If results indicate you are under 90% accuracy, more frequent reviews are beneficial.