7 Deadly Sins of Outpatient Documentation

7 Deadly Sins of Outpatient Documentation

Correct bad habits before your E/M services claims are audited.

by Tim Stelma, BA, CPC, CPMA, AAPC Professional

Auto-fill and self-leveling functions in electronic healthcare records (EHRs) have led to higher utilization of upper-level evaluation and management (E/M) services. This has not gone unnoticed by insurance carriers. To dodge a large take-back resulting from a failed audit, thou shalt not commit these seven deadly documentation sins.

I Thou shalt not document fewer than four HPI.

This is number one for a good reason: It’s the only part of the history and examination that can’t be auto-filled. Providers must collect this information personally; any indication they have not spells big trouble.

Recording four clear elements of the history of present illness (HPI) should be a standard operating procedure for every patient who walks into the office. It’s that important.

II Thou shalt not document contradictions.

The physician notes, “Patient presents with a chief complaint of a cough.” But in the respiratory review of systems (ROS), it says “No cough.”

A contradiction such as this can result from cloning or auto-filling documentation in the EHR. It’s a good way to get the entire ROS thrown out. Worse yet, if the physical examination contradicts the chief complaint or HPI, the examination section could be reduced to vital signs only.

III Thou shalt not skip assigning status to chronic conditions.

This is a common omission in the medical record. Recording blood pressure only for a patient with hypertension does not give the auditor anything to work with. Is it stable or worsening? “Patient tests blood sugar daily” is also a head-scratcher.

Auditors can only assume conditions are stable unless stated otherwise. This leaves the provider with only two diagnosis and treatment options for a diabetes mellitus/hypertension (HTN) monthly visit, which — in the absence of multiple data points — levels to 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity for an established patient, instead of 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.

IV Thou shalt not code conditions not addressed or treated.

This issue is a subset of the third deadliest sin: If HTN is not addressed or did not figure into the treatment of the presenting problem, it should not be considered when assigning an E/M service level. Many times the blood pressure reading in the vital signs is “textbook.”

Never code unaddressed chronic conditions simply to raise the service level.

V Thou Shalt Not Code Associated Signs and Symptoms.

Coding signs and symptoms commonly associated with a condition will not raise the level of service. Auditors will ignore these diagnosis codes when leveling the visit.

VI Thou shalt not make the auditor guess if this is a new problem.

If there is no indication whether the presenting problem is new, the auditor may not have access (or the patience) to investigate prior visits, and assume it was treated previously. Documenting the information does not add to HPI elements, but it figures into the medical decision-making level.

VII Thou shalt not overestimate risk.

In examining high complexity elements in the Table of Risk, you’ll see the presenting problems are quite serious — acute myocardial infarction, severe exacerbation of a chronic condition, etc. Many of these elements require a trip to the hospital.

There are also two often misunderstood key phrases in the management options: “Identified risk factors” refers to comorbidities that could affect or complicate the outcome of the surgery, not the surgical procedure risk itself; and “parenteral controlled substances” means “situated or occurring outside the intestine,” so any controlled substance prescribed and administered by mouth would not qualify as high risk.

Level fives are the highest paying office visit codes, so they are naturally flagged when high utilization is noted in insurance carrier reports. The provider will take a big hit in the pocketbook if an opportunity to re-bill is not offered post-audit.

If you find any of these errors while reviewing provider medical records, suggest corrective actions to ensure a positive outcome from an audit. When it comes to audits, it’s not a question of if, but when. Stay prepared.

Evaluation and Management – CEMC


Tim Stelma, BA, CPC, CPMA, AAPC Professional, transitioned from the manufacturing industry to a career in coding in 2011 and specializes in E/M services and provider education for Proactive Coding Consultants located in Chesterfield, Mich. He is a member of the Detroit, Mich., local chapter.

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