What Lies Beyond the Labels?
by Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA
A wise shopper with an interest in purchasing wholesome, nourishing food products will read the label on products. A shopper deciding among many products to help control weeds in the lawn will gain invaluable information from reading the label. A patient who has been prescribed medication will read the label to understand dosage and special instructions. There are many places in our lives where reading the label protects and informs us.
Reliance on the “label” when auditing evaluation and management (E/M) services could lead to flawed auditing decisions. Let’s consider a typical kind of chart review where the auditing/review personnel read the medical record and compare the category and level of the evaluation and management code assigned to the documentation found describing the visit.
Electronic medical records are frequently organized with labels (or headers) describing the information that will follow. For the sake of this discussion, let’s assume the reviewer is evaluating the examination portion of the medical record and the billing code requires a comprehensive examination. To focus our attention, we will assume that medical necessity, complexity of medical decision making and history support the “target code.”
To determine if the documented examination is comprehensive we must first determine if we will use CMS’ 1995 or 1997 Documentation Guidelines for Evaluation and Management Services as the standard. Following CMS’ standard to use the version most favorable to the provider, we will for this example use 1995 criteria, requiring information from each of eight organ systems. Consider how the following documentation examples represent portions of an examination.
Example 1: HEENT: PERRLA, sclera non-interic.
A reviewer reading too quickly and placing too much reliance on the header might give credit for both “Eyes” and “Ears, Nose, Throat” organ systems but this example provides no information about the ENT.
Example 2: Extremities: Full ROM, +2 DP, sensation intact to pinprick.
Relying on this heading may not allow any credit because “extremities” is not an organ system. However, careful reading of the information shows us that the provider documented information about three organ systems: musculoskeletal, cardiovascular, and neurological during the examination of the extremities.
We learn the importance of documentation from CMS’ Documentation Guidelines for Evaluation and Management services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf.
WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. care; accurate and timely claims review and payment; appropriate utilization review and quality of care evaluations; and collection of data that may be useful for research and education.
Notice the guidelines do not dictate a specific format for the information. Unlike the agencies overseeing the appropriate labelling of food, herbicides, and medications, we do not have to label any section of the medical record. Even when the labels are a part of the provider’s documentation style and/or template, it is our job as auditors to ensure that we review the detailed information. Be sure to look beyond the label!