Oncology & Hematology Coding Alert

Warning: Cloned notes aren't just a risk with EHR.

If you're concerned your practice could be in an E/M coding rut, check out the following tips shared during the recent webinar, "E/M: Introducing the Guidelines," presented on Jan. 18, 2012, by Palmetto GBA, a Part B MAC.

1. Avoid Writing the Same Thing for Every Patient. Although you might think of "cloned documentation" as only existing when using electronic health records (EHRs), the truth is that even paper records can be considered "cloned" if they are all worded exactly alike.

"Whether the cloned documentation is handwritten, the result of a pre-printed template, or use electronic health records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services," said Carrie Weiss, senior provider education consultant with Palmetto, during the call.

Even if you see seven patients with the same diagnosis on the same date of service, they won't all have the same history, symptoms, treatment recommendation, or prognosis, so copying documentation from one patient to the next is inappropriate. The notes should be tailored to each patient's individual case.

2. Provider Signatures Must Be Legible. Practitioners who are signing documentation by hand should ensure that they include both their first and last names, and that the signature is legible. In addition, Weiss said, Palmetto recommends that practitioners include their credentials (such as MD, DO, PA, etc.) after their signature.

If a signature is illegible, auditors will use a signature log or attestation statement to determine who authored a medical record entry, but if a signature is missing from an order for other services, the order will be disregarded, just as if it didn't exist.

3. Don't Mix and Match 1995 and 1997 Guidelines During the Same Visit. Most coders are familiar with both sets of Medicare guidelines when selecting an E/M code, but what some practices don't know is that you can't choose from both sets of guidelines a la carte during the same patient encounter.

"You cannot interchange the two guidelines," Weiss said. "So once you start out using a set of guidelines, you must continue using that set of guidelines. That doesn't mean that at the next visit you can't use the other set of guidelines; but per encounter, you must stick to one," she said.