Five Tips for Coding-friendly Documentation
Meeting documentation requirements for coding shouldn’t be a burden. Five pointers can go a long way to ensure that your documentation leads to accurate coding for the services you provide.
1. Document Your Decision Making
In the eyes of a coder (or auditor), “Not documented = Not done.” But, the provider can’t document everything, and irrelevant details can be as bad as too few details.
The best documentation captures the provider’s clinical decision-making process. What is the purpose of the visit? What information about this patient is relevant to his or her complaint? How does the provider use that information to develop a diagnosis and plan of care? If you can capture that information, accurate coding will follow.
2. Legibility Matters
A corollary to “not documented = not done” is, “If it can’t be read, it can’t be considered.” The details of your documentation might be scrupulous, but it won’t matter if handwriting is too challenging to decipher.
If your penmanship is hopeless, consider an electronic health record and/or employing scribes. If you don’t already have one, consider adopting a legibility standard in your practice or facility.
3. Document a Chief Complain—Yourself
The treating provider—not ancillary staff—should always document the patient’s chief complaint. The 1995 and 1997 Documentation Guidelines for Evaluation and Management Services allow that any review of systems (ROS) and/or past, family, and social history (PFSH), “may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation, supplementing or confirming the information recorded by others.”
4. Be Specific
When documenting a clinical condition, always be as specific as possible in your diagnosis. Diagnosis codes, derived from the patient record, provide justification for the services and procedures billed. The more precise the documented diagnosis, the better supported the claim will be, and the less likely payers will be to reject payment based on lack of medical necessity.
According to the ICD-9-CM Official Coding Guidelines, in addition to describing “the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided,” you should also document “conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”
As above, if the information is relevant to the clinical decision-making process, you should document it.
5. Sign Your Work
The physician’s signature identifies who ordered or provided the service, and signifies that the provider has confirmed the medical necessity for the services submitted for payments. Each signature must be legible, and should include first and last name.
Acceptable methods of signing records/tests orders and findings include:
- Handwritten signatures or initials
- Electronic signature (includes date and timestamps, and usually a printed statement such as “electronically signed by” or “verified/reviewed by,” followed by the practitioner’s name and professional designation)
- Digital signature (Typically generated by encrypted software that allows for sole use)
For most payers, signature stamps alone are not valid, and may result in payment denials.
Additionally, Medicare (and most other) payers require that diagnostic tests (X-ray, labs., etc.) must be ordered by “the physician who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem.” Not signing your orders can be costly: Payers will deem diagnostic tests not verifiably ordered by the treating physician as “not reasonable and necessary,” and will not pay for such tests.