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Watch Out for These 7 Clinical Documentation Pitfalls

Watch Out for These 7 Clinical Documentation Pitfalls

Keep high-risk areas in mind as you strive to improve documentation practices and procedures.

With automated medical resources, such as electronic health records (EHRs), computer-assisted encoders, claim scrubbers, and interrelated workflow processes, there is often much to be desired when the provider’s documentation — including operative notes, daily progress reports, consults, lab and radiology notes, durable medical equipment orders, and other sources — reaches the coder’s desk for validation prior to claim submission. To hone in on areas of risk, consider the following seven keys for clinical documentation improvement (CDI).

1. Copy-and-Paste and Template Macros

The ability to copy and paste documentation in the EHR has seemingly become a necessary function, and this is quite efficient in terms of scale economy, but only up to a point. It is inappropriate to copy and paste information when it has the potential to change from one visit to the next or from one patient to another.

  • To avoid erroneous documentation, providers should:
  • Never include a hard number (a constant) in a macro. This is because patient conditions and related measurements change (and hopefully improve) over time, and should be reflected in ongoing patient care.
  • Update macros as dictated by corporate, governmental, or any other change in the industry.
  • Use the right template, which may vary depending on visit type.
  • Review problem lists for accuracy if copying and pasting them from one note to another.

Coders and practitioners should work together to design suitable canned text that meshes well with elements of the note that have the potential to vary from visit to visit.

2. Active, Relevant Diagnoses

It is important that the codes derived from a clinical note reflect only active diagnoses, comorbidities, and history/status situations that might affect patient outcomes. Conditions that no longer exist or have no bearing on the care the patient is seeking, such as when visiting a specialist, should not be coded. Ideally, past problems should not be addressed in the medical note except as a historical notation in the problem list. If a condition is fully resolved and the patient is simply coming in for a follow-up visit, such as for management to prevent a relapse, the condition previously treated is history and should not be coded as an active diagnosis. Where appropriate, a Z code could be attached to indicate personal history or a status that is worthy of consideration (for example, sequela from an old injury). By the same token, we want to make sure we do capture everything that may be pertinent to “whole patient” management style.

3. Contradictory, Erroneous, or Confusing Text

Both practitioners and coders should be privy to all text dictated into an EHR chart. One potential pitfall is a language barrier, where key bits of information can get lost in translation or dictated incorrectly because of vocal inflections picked up (or not picked up when they should be) by the voice synthesizer. This will lead to frequent errors in the note such as a patient’s age, or worse, a medication regimen. For instance, it’s easy to mistake 15 mg for 50 mg when there’s no human interaction involved in the transcription process.

One possible exception is information the coder knows is boilerplate or standard procedure such as the details of a surgical prep. The coder should read the entire note to make sure the diagnostic theme is consistent and unambiguous and there are no dictation errors. The coder should watch out for inconsistencies such as laterality, gender, or diagnosis classification. It’s best to have checkpoints installed on the practice’s end to catch these mistakes and minimize the amount of erroneous documentation the coder must review.

4. Gender and Sex Specificity

The provider and support staff should be vigilant of a patient’s sex and gender, not only at registration and during the visit but also while documenting/reviewing the encounter. Sometimes one cannot tell a patient’s sex or gender simply from their first name and must look to verify it in the registration information. Occasionally, a patient’s sex or gender is misstated within the body of a progress or operative note. Coders should be wary of diagnoses and procedures reported by the provider that are mismatched with the patient’s sex and gender identification. Claim editors may pick up on such errors, but not always, and the erroneous claim may get processed by the payer.

5. Coder-Friendly Diagnostic Terms

Providers should avoid documenting vague or broad terms, such as injury, defect, lesion, or infection, without elaborating as to the nature of the condition and, when applicable, its etiology and/or related manifestations. If a pathological analysis is necessary to determine diagnosis specificity, the coder should wait for the pathology report to come back with a result, which perhaps takes two to three business days. Documentation of general terms can map out to numerous ICD-10-CM codes, increasing the volume of claim edits for unspecified codes (both front-end and back-end) and provider queries, which would otherwise be unnecessary. This takes teamwork between coders and practitioners; periodic and dynamic physician education may be necessary.

6. Information Hiding

Protected health information (PHI) should be just that — protected and privileged. For starters, PHI should not appear in the body of a clinical note. The text should not read, “Sally Smith is a 74-year-old woman ….” Rather, the patient’s name should be substituted with a nondescript word such as “patient” or “subject” that does not reveal the patient’s identity. The main reason for this convention is that, in the event textual matter of the note needs to be reproduced with all personal health information redacted, the PHI elements are unlikely to be overlooked during the redaction process. PHI, such as the patient’s full name, date of birth, medical record number, or any other internal identifier, should appear only within the header of the note.

7. Record Redaction

The concept of information hiding segues into my final consideration for CDI, and that is the process of PHI redaction. There is really only one proper way to redact a hard copy of a clinical note. Taking a black permanent marker to the PHI is the first necessary step, but that alone is not sufficient. Next, you must make a copy of the redacted note and protectively discard the original. The reason for taking this extra step is that if someone turns the original note over, it may be possible to see where the marker bled through and read a backward image of the patient’s PHI. Also, anyone who touches the note must make sure all elements of the PHI are completely blacked out. Correction fluid, such as “white-out,” is not recommended because the solution typically does not settle thick enough to fully obliterate print — it can be scraped off, and the note is messy or otherwise difficult to copy.

Clinical documentation integrity affects the entire revenue cycle, from providers to coders and billers to payers and beyond. Most importantly, CDI affects patient care. This is where human coders will continue to play key roles in validating provider documentation and HIPAA compliance. I emphasize “human coders” because encoding tools and resources obtained via internet research are really only as good as the person who utilizes these resources, especially when it comes to selection of unspecified or vague catchall ICD-10-CM codes.

Coders need to meet continually and on an as-needed basis with practitioners and the practice staff they manage to make sure everyone involved is adhering to production of documentation that conforms to accepted corporate practices and external compliance standards. When providers and their coders are onboard and working as a team, CDI will improve tremendously.

Ken Camilleis

About Has 5 Posts

Ken Camilleis, CPC, CPC-I, COSC, CMRS, CCS-P, is a full-time professional medical coder and has taught coding at career schools around Massachusetts. He has been pursuing provider education programs including clinical documentation integrity projects. Camilleis is the 2022 member development officer for Cape Coders, the Hyannis, Mass., local chapter.

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