Documentation Templates Can Cause Compliance Problems

Strong documentation is the key to accurate coding. Without precise and detailed clinical notes, compliance risks increase and reimbursements are reduced. ReveNews recently spoke with web2pro certified coders about common documentation errors across a variety of physician specialties.

For independent practices, documentation problems frequently stem from what’s known as “click-happy” physicians, according to Cindy Cain, BSHA, CPC, CPC-H, CCS-P, CHC, a senior coding manager with web2pro Business Performance Services (web2pro.)

A click-happy doctor is one that checks boxes in an electronic health record (EHR) template that are unrelated to -- or only peripherally associated with -- the service provided. The physician may believe that checking a range of boxes will cover all aspects of the care, but this approach is careless and can increase the likelihood of a punitive audit, Cain said.

A similar problem, she added, involves “cutting and pasting” information from a patient’s previous, unrelated visit into the current clinical documentation template. Although ostensibly done to save time, this shortcut can also raise compliance and audit hazards.

Providing Feedback

Cain said practices that use documentation templates should review them at least once a year to check that all fields are current and relevant. And regardless of whether practices do their own coding or rely on a third party, it is important to establish a formal process for providing feedback to physicians regarding their documentation accuracy. 

Instituting this step will help address chronic errors and omissions. It will also create a regular opportunity to bring physicians up to speed on new or changing documentation requirements.

Groups that code internally may also wish to enlist a qualified third party to provide periodic coding audits, Cain said. These assessments will not only identify documentation errors by physicians but also flag mistakes made by coders. Again, the objective is to optimize collections based on accurate documentation while reducing or eliminating compliance risk.

“All practices should develop processes for reviewing their templates and for providing feedback through regular coding audits,” she said. “Too often, we see physicians who are operating in a vacuum, without the benefit of any feedback in the way they code. The result is that errors become systemic.”

Charting Accuracy

Beyond problems with documentation, poor clinical charting can also negatively affect coding, claims and revenue. For example, a nurse’s failure to document pertinent drug information can affect the level at which the visit is billed. Similarly, nurse actions that go unrecorded -- such as observing infection around a drainage tube – may contribute to a lower code for the visit.

Nurses should confirm that all physician orders are carried out and appropriately documented. This includes everything from x-rays and lab work to drawing blood for a hemoglobin check. Cain said the failure to document routine physician orders often occurs in busy offices with high-patient volumes.

“It’s the 40th patient of the day, it’s already six o’clock, there’s just one nurse to finish up the last two patients and the doctor orders a steroid injection for bronchitis,” she said. “Both the doctor and nurse know the injection was provided, but unless someone documents it, it can’t be billed. This kind of thing happens a lot. People get in a hurry and forget. It’s human nature.”

Doing the Right Thing

Most physicians, of course, understand that good clinical documentation is essential not only for communicating effectively with other providers, but also to provide the legal foundation for billing. As a result, the vast majority strive to make documentation legible, timely, complete and precise.

One key for engaging physicians in the documentation process is to show how clinical documentation frequently serves as the basis for demonstrating the quality of care provided. With today’s emphasis on quality care and pay-for-performance contracting, providing clinical detail has become increasingly important. 

For example, a diagnosis of congestive heart failure, not otherwise specified (CHF NOS) may be acceptable for a general practice physician. However, this lack of specificity on the hospital record can affect payment.

The message for physicians is simple: Good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, validate the care that was provided, facilitate accurate reimbursement, and show compliance with quality and safety guidelines.

Sometimes, the simplest reminder is the most effective, Cain said. “If you didn’t write it, it did not happen and it cannot be billed.”

And as important as accuracy is in today’s environment, detailed and precise clinical notes will become even more essential once the ICD-10 code sets take effect in October of this year, she said. ICD-10 documentation requires considerably more clinical and anatomical specificity than the current ICD-9 system.


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.