EHR Warning: Under-documenting Is as Harmful as Over-documenting

In the age of electronic health records (EHRs), patient encounter notes may become bloated with extensive histories, medication lists, and laboratory and radiology results that may not have been obtained during—and which are not pertinent to—the present visit. Ironically, physicians may have an overabundance of patient information, but fail to document some of the work they actually did, which can adversely affect the level of service reported.
In the outpatient/clinic setting, physicians perform a great deal of behind-the-scenes work to diagnose and treat patients. For instance, they review patient records, talk with other providers, order and review tests, and coordinate care. Most of these activities cannot be counted if the provider is billing based on time because they occur before or after the patient’s visit. Physicians must describe this work in their notes, so the effort may be captured when the note is coded according to the elements of history, exam, and medical decision-making (MDM).
Determine if Your Physician Is Under-documenting
As a coder and a compliance specialist, I have reviewed tens of thousands of notes and have talked with hundreds of providers. Continually, certain items of MDM—diagnosis, data, and risk—go undocumented or unlabeled, and are unused when determining a level of service. Often, physicians are not upcoding as much as they are under-documenting the services they perform. To help prevent this, I ask physicians a series of questions when I meet with them:
I see you have a number of patient complaints listed in your HPI, but not all of them are documented in your Assessment and Plan. Did you address any of these issues during the visit? 
If the physician did address the complaints during the visit, they must be listed to substantiate that the physician was dealing with more than one health issue. This may increase the level of MDM—and possibly, the level of service.
Are you performing a record review?
Often, the record review summary is integrated within the HPI. When many specific dates, lab findings, and other detailed information are given in the HPI, ask the physician about the source of the data. If the record review is not separated from the HPI and labeled, the information may be attributed to HPI only, and he or she may not get credit in the MDM section for this work.
Do you review the patient’s images or slides yourself? 
If the physician performs this service and documents it, this may elevate the level of MDM.
Do you talk with the radiologist or pathologist? 

Talking with the testing physicians can contribute to a higher level of MDM, when performed and documented.
Do you order additional records?
Sometimes patient records are not available for review before their visit. Obtaining additional information in a medical record can increase the MDM and, possibly, the level of service.
Is your patient on a drug therapy requiring intensive monitoring for toxicity?

Many drugs require a patient to undergo frequent laboratory work to determine if the dose or the drug itself is causing adverse effects. “Intensive” is open to interpretation, but most payers would not consider testing for toxicity once or twice a year to be intensive.
Use Templates Wisely to Ease Documentation

Physicians may balk at having to document more than they already are. EHR templates can be set up with prompts or phrases that would be routinely used. We use the Epic system, and we have created phrases that the physician can select when appropriate.
These include:

• “This patient is on <drug name> requiring intensive monitoring for which I have ordered labs to check toxicity levels.”
• “I have performed a record review. Pertinent details include: …”
• “I independently reviewed the patient’s images. My findings are: …”

Does it make a difference in the level of service if the physicians document all of the work they do? Yes! Maybe not for every visit, but for some it could make a big difference.
EHR Scenario Reveals
Let’s take a look at a hematology/oncology example:
A new patient comes in to discuss treatment options for a newly diagnosed cancer, for which the patient has few symptoms and is doing well. The physician documents a comprehensive history and exam, orders labs, pulls in other lab work and radiology from the EHR system, and discusses the need for chemotherapy. The documentation shows:
Diagnosis: New problem needing work up (4 points – high complexity)
Data: Lab and radiology review (2 points – low complexity)
Risk: Prescription drug management (moderate complexity), new problem with uncertain prognosis (moderate complexity)
Based on the above documentation, the visit would equate to a 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity.
But I suspect this documentation doesn’t tell the whole story. Let’s say we meet with this physician and ask all of the aforementioned questions. The physician tells us that he did a record review and looked at the patient’s images himself. With this new information and improved documentation, we can reconsider the level of service:
Diagnosis: New problem needing work up (4 points – high complexity)
Data: Record review (2 points), independent review of images (2 points), orders additional lab work (1 point): Total of 5 points = high complexity
Risk: Prescription drug management (moderate complexity), new problem with uncertain prognosis (moderate complexity)
Based on the additional data the physician reviewed, the improved documentation changes the level of service to 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. The original documentation showed a low complexity for data; whereas, the improved documentation shows high complexity. What’s the difference? About $40 for each visit of this nature.
Erin Andersen, CPC, CHC, has worked in coding and compliance since 2003 at Oregon Health & Science University performing chart audits and educating providers, coders, and staff about coding and billing. She is the education officer in the Rose City AAPC Local Chapter in Portland, Ore., and one of the Region 8 representatives on the AAPCCA Board of Directors.