ED Coding and Reimbursement Alert

These reviews are quick, inexpensive, and effective.

As you prepare for the calendar to turn to 2021, it’s a good time to revisit your documentation practices. Although specific CPT^® codes may come and go when one year ends and another begins, strong documentation processes will always be essential.

One way to ensure that your documentation is as strong as possible is to perform peer audits, which can allow you to get a unique view of how another clinician might interpret your charts.

Find out What’s Involved

To perform a peer audit, you’ll ask a colleague to review your documentation without revealing which treatment decisions or codes you selected for the encounter.

“What we really want to see is that your peers would be able to manage the patient in the same way you did based on the information you provided,” says Meri Harrington, CPC, CEMC, of Brown Consulting Associates. “Can they gather that information just from looking at your records? If we have very succinct, non-detailed documentation, then it’s not a quality medical record.”

Ask another clinician to look at your documentation and determine what treatment decisions they would make based on what they’re reading. “Without the knowledge that’s in the treating clinician’s head, could a peer review the record and make the same treatment decisions based on what you documented? If not, then you may need to add detail to your documentation,” she says.

Check This Example

Let’s say you see a 7-year-old patient who presents with ear pain and a sore throat. The documentation notes, “On examination, the patient had impacted cerumen bilaterally, which I removed to improve visualization. The patient had some minor redness in the left ear but the right ear appeared normal. Her throat appeared red and her glands were tender.”

Although the peer reviewer wouldn’t get to see the treatment provided, this physician documented that they prescribed antibiotics to treat the patient’s strep throat.

However, the peer reviewer would likely surmise that this patient was discharged from the ED without any treatment, since no documentation of otitis media, a strep test, or a positive strep result were documented.

The peer review would therefore show the ED physician that they should be more diligent about documenting tests ordered, test results, and final diagnoses observed.

Ensure Unique Documentation

One issue that every clinician should consider double-checking is whether they’re carrying forward information in their electronic health records using copy/pasting techniques without adding details about the current encounter.

If you’re seeing a patient who you saw the prior day and you want to pull forward that previous information, that’s okay — but you should also document how the patient has been doing since the last encounter. “There should be a unique story for today and copy/pasting often gets in the way of that significantly.”

Here’s How to Get Started

If you’d like to perform a peer audit, you don’t need any special training to do it. Your clinicians should select five to 10 encounter notes with the treatment plans redacted, and then exchange them with other clinicians within the ED. Ask the providers what treatment plans they would recommend based on your documentation, and if they identify holes in your documentation through this practice, take note of the areas where your records need additional work.

You can perform these types of audits a few times a year to ensure that your documentation remains solid over time. The next natural step would be to perform a formal coding audit on these records. Have the coding staff review the same documentation and determine which codes they would report for the encounters. If the coders’ recommendations don’t match what the providers reported, then you may need to perform a full-scale coding audit to ensure that the charts in your ED are being coded accurately.