Neurosurgery Coding Alert

The documentation should describe each diagnosis succinctly and to the highest level of specificity.

Improving the medical documentation in your neurosurgery practice is an important step to submitting cleaner claims. At the recent Virtual HEALTHCON session “Importance of Accurate Documentation & Coding; A Physician’s Perspective,” Rae Godsey, DO, associate vice president/corporate medical director, risk adjustment and stars at Humana, outlined three areas physicians can focus on to improve their medical documentation. She also touched upon best-practice documentation principles practices can follow.

Area 1: Observe Ways to Improve HPI

In her talk, Godsey outlined specific areas of a medical note where physicians and healthcare providers can improve upon when it comes to best documentation practices, including the history of present illness (HPI).

Godsey gives a typical example of common documentation for HPI: “The patient presents today for follow-up. Patient seems to be improving and has no new complaints. We’ll plan to see him back in three months.”

However, this HPI lacks the detail needed, Godsey says. HPI sets the background of the patient’s presenting problems from when the symptoms started to the encounter, so it’s important to be specific.

Godsey offers this example as an HPI best practice instead: “The patient presents today for follow-up on his Type 2 diabetes. He has had Type 2 diabetes for approximately the past 14 years, which was getting out of control. The patient now keeps a diet and exercise log, in addition to the changes in Lantus we made at the last visit. There is an improvement in his blood sugars that he has been recording at home.”

With the HPI, you are setting the stage for someone who may read the note and know nothing about the patient, Godsey explains. If you don’t put the information somewhere in the note, the end reader will not clearly see the picture you are painting.

“The physician should include what conditions the patient is diagnosed with, why she arrived at this diagnosis, the clinical signs and symptoms, and the assessment and plan (A/P),” according to Godsey.

Area 2: Include Just Enough ROS Info

The review of systems (ROS) is another area where practices can improve relating to medical documentation.

“Sometimes the ROS is lacking,” Godsey says. “It’s not there at all or it’s too much.”

For a sick visit or if the patient is there for a 15- or 20-minute visit, this should not include an entire ROS, Godsey explains. However, if the provider is performing the physical part of an annual wellness visit or an annual physical, it would be appropriate to include a full ROS.

An ROS can be obtained from the patient, according to Godsey. They can complete it before the visit. Or they can complete as a conversation between the physician and the patient during the encounter.

Take a look at the following less-than-ideal ROS from Godsey: ROS: As per HPI: “The patient has complained of a cough for the past three days. She has tried over the counter sinus medication without relief. There are no other complaints at this time.”

With this example, there is not enough information in the HPI to support the ROS, Godsey explains.

Area 3: Look at A/P Examples

The third area where medical documentation can be improved is the assessment and plan (A/P). Godsey gives a common example of an A/P you might see in medical documentation:

• Diabetes
• Hypertension
• Osteoporosis
• S/P coronary artery bypass graft (CABG) 2008
• Migraines
• Gout

Godsey also gives a best practice example of the above A/P: “Type I diabetes- no changes in medication at this time. Will check A1C in three months prior to the next visit. Hypertension- stable on Triamterene 37.5 mg, with no changes in dosage. Migraines- followed by Dr. Smith-current medication are not affecting the hypertension.”

With this best practice A/P, you know exactly what conditions the patient has been diagnosed with and what the treatment plan is, Godsey explains.

“The A/P should explain what was found, what labs were performed, the X-rays or other services that were ordered or performed, and the expected outcome by the next visit, Godsey says. “It’s important to include as much information as you can, but it must be pertinent information that speaks to the end reader.”

Follow These 7 Best Medical Record Documentation Practices

Godsey also identifies principles that practices physicians and healthcare providers can follow to make sure they craft stellar medical record documentation.

Principle 1: Clarity: The documentation should communicate to all readers the documenter’s intent.

Principle 2: Concise: The documentation should describe each diagnosis succinctly and to the highest level of specificity.

Principle 3: Consistency: The documentation should avoid conflicts or contradictions with information throughout the record.

The provider using a recorder that types as they speak into it can lead to inconsistency, Godsey explains. With the recorder, sometimes it might not pick up or the voice recognition will be lacking. For example, the provider might say the word, “he,” but it comes out as “she.”

Gender conflict is one situation where a coder may need to query a physician.

When it comes to querying, many physicians don’t understand risk adjustment, so they take the querying to heart, and they may take it as if you are questioning their clinical knowledge or medical decision making (MDM), Godsey says. So, be sensitive to this, and point out that is not what you are doing. You are just trying to capture the most accurate documentation within the note to support the codes the healthcare provider put into the chart.

Principle 4: Completeness: The documentation should include all of the conditions evaluated and treated, as well as all chronic or other conditions that affect patient care, treatment, or management. The documentation should also include the date of service, the patient’s name, the provider’s credentials, and a timely signature.

Principle 5: Legibility: The documentation should be completely legible to any objective reader of the record.

Principle 6: Specificity: It’s more important than ever to be specific with diagnosis codes, Godsey says. For the documentation to become more specific, you can include the following pertinent pieces of information:

• Type
• Morphology
• Site, including laterality and specific location within body part
• Temporal parameters
• Severity
• Symptoms
• Causality
• Episode of care
• Remission status
• Complications

Principle 7: Certainty. You should avoid terms that imply uncertainty. Don’t use terms like “probable,” “apparently,” “likely” or “consistent with” to describe confirmed diagnoses, Godsey says. You also should not document uncertain diagnoses as if they are confirmed. Instead, you should document the signs and symptoms in the absence of a confirmed diagnosis.

Editor’s note: Want more great info like this? You can now register for the upcoming 2020 HEALTHCON regional conferences: https://www.aapc.com/medical-coding-education/conferences/. Also, early bird registration is open for 2021 HEALTHCON in Dallas. Visit www.aapc.com for more info.