Let Documentation Drive Your Coding

Here’s what to do when your provider’s documentation takes a back seat.

By Robyn Margani, CPC

If it isn’t documented, it wasn’t done. That’s the golden rule of coding. As we’ve all been told again and again, inaccurate documentation can lead to improper payments, non-compliance with government and insurance regulations, and audit risks. Unfortunately, the demands of a busy patient schedule, incoming calls and emails, and managing a staff and a practice mean that, for some providers, documentation sometimes takes a back seat.

Evaluation and Management – CEMC

Coders can help improve documentation, and have a responsibility to provide physicians with constructive feedback on areas of improvement. It is equally important for staff members to research and provide their physicians with solid information from authoritative sources. Here are some key points to remember when advising physicians on the importance of accurate and complete documentation.

Reports Don’t Need to Be Lengthy to Be Complete

For each patient service, there are minimum requirements of what must be included in the medical record. For example, in most cases an evaluation and management (E/M) must have history of present illness (HPI), examination, and medical decision making (MDM) components (see your CPT® codebook for exceptions).

Radiology reports must document technique as well as findings of the study. For example, consider an ultrasound of the thyroid with a duplex study: The record should include the technique for the ultrasound and all findings, as well as a separate area discussing inflow and outflow, vascular structure, and any relevant findings. You don’t need the equivalent of two standalone reports to be complete. Omit just a few words, however, and coding the additional study becomes questionable.

Documentation Must Be Relevant

I once provided E/M documentation training to a group of physicians who were reluctant to receive it. They felt they were doing just fine. Following the training, I began to receive reports including lines in the exam portion such as, “The patient has a round head, two eyes, two ears on opposing sides of the round head,” etc. Not only did the doctors not improve their documentation to support a higher level of E/M service, they received a letter from a large insurance carrier stating they were doing an extended audit of their E/M services.

Extraneous documentation can sometimes do more harm than good. It can raise a red flag with the carriers that your provider is trying to upcode by doing more work than is necessary for the service. My advice to physicians is stick to what’s relevant and be thorough.

Documentation Must Support Specific Coding

CPT® instructs you to select the code that accurately identifies the service or procedure performed. You should not select a CPT® code that merely approximates the service provided. Documentation must support the code you select. Implied meanings and assuming something is done when it is not written in the record is where the trouble begins.

Let’s look at one example of a common service in radiology:

Computed tomography angiography (CTA) is used to evaluate a patient’s blood vessels and can detect stenosis and aneurysm (among other things) in the vascular system. According to the American Medical Association (AMA), CTA requires 3-D angiographic rendering. Acceptable terms used to describe 3-D postprocessing include maximum intensity projection (MIP), shaded surface rendering, and volume rendering, along with the term 3-D.

A typical chest CTA report may read:

During the intravenous administration of 100 cc of contrast material, spiral scans of vascular structure obtained from the lung apices through the adrenal glands were performed.

The report may even go on to state, “reformatted reconstructions were obtained.”

Clinically, we know the doctor performed a CTA. He or she is reviewing the vascular structure. The history likely supports this, as well; however, without one of the terms above (MIP, shaded surface rendering, etc.), coding this as a CTA would be inappropriate. If this report went for medical review, the service would not be considered a CTA. If this had been submitted as a CTA, the result would be returned monies (if already paid), a broader request for records and audits, and potential reporting to the authorities as fraud.

The inclusion of one of the terms above changes the whole thing. Let’s look at this same example, but now the additional line states, “3-D reformatted reconstructions were obtained.” The addition of two letters changes everything. This documentation now supports a CTA; and, if the records were requested for review, everyone could rest easier knowing their documentation is up to par.

Document Same-day Procedure, E/M with Special Care

Let’s look at another common problem with documentation that can raise red flags: Procedures provided the same day as an E/M service.

For example, a patient comes in for a scheduled knee joint injection for pain and arthritis. The service includes evaluating the patient to ensure he is able to receive the service. While he is there, the patient mentions he has been having some mild headaches and pressure over the past week. The doctor determines the patient has sinusitis and suggests over-the-counter decongestants and nasal saline washes.

When reporting an additional study, the documentation must pass what is referred to as the “highlighter test.” When all the elements have been highlighted to support the initial service, what’s left to support the additional service? In this scenario the documentation may read something like this:

Established patient with cc knee pain, patient with known osteoarthritis uncontrolled with OTC pain-relievers, presents today for cortisone injection. Patient also complains today of mild headache and facial pressure over the past week.

HEENT exam shows inflammation of the maxillary sinus with some minor congestion. Moderate swelling and stiffness of the left knee compared to right. Some pain with rotation.

Patient informed of risks and benefits and wishes to proceed. Knee prepped with alcohol and 3 cc of hydrocortisone injected into the intra-articular left knee space. Patient tolerated procedure well. Advised to proceed to ER if any adverse reactions occur after leaving the office. Instructed OTC decongestant and saline nasal spray for sinusitis.

Let’s deconstruct this record and see what services it supports. Start by highlighting the knee injection. We’ve got the first line directly related to why the patient was scheduled for the appointment. A limited exam of the affected area is documented in the following paragraph. The remainder of the note talks about the procedure performed.

The injection is supported in this report. After we highlight all those lines, what’s left?

Patient also complains today of mild headache and facial pressure over the past week. HEENT exam shows inflammation of the maxillary sinus with some minor congestion. Instructed OTC decongestant and saline nasal spray for sinusitis.

We’ve covered history, exam, and MDM with a diagnosis of sinusitis. This is enough for a separately identified E/M service (limited, yes, but a visit can be billed, nonetheless). Just be sure to use modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service when billing an E/M on the same date as a procedure.

CMS transmittal 954 (MLN Matters® MM5025, change request (CR) 5025, May 19, 2006) states specifically that you should apply modifier 25 only for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service.”

It is important to remember that the only proof of what was performed is what is written in the documentation. Without getting it in writing, it is just a memory of the physician, and nothing more.


Robyn Margani, CPC, is the director of coding operations for Healthcare Administrative Partners, LLC, a large multi-specialty revenue cycle management company in Media, Pa. Robyn plays a key role in the strategy, planning, development, implementation, and maintenance of coding processes, policies, and education to ensure compliance and to maximize physician reimbursement.


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