Part B Insider (Multispecialty) Coding Alert

Published on Thu Nov 10, 2005 PDF

Teach your doctors to be more precise in E/M documentation

Sure, the carriers are coming up with new and clever ways to poke holes in your evaluation and management documentation, and Medicare is sending more kinds of auditors to look at your claims. But that just means you have to be even more careful about keeping good documentation for your E/M visits .

As carriers like TrailBlazer create their own audit tools for E/M visits, you should be making sure your records are as airtight  as possible, say experts. And one way you could be leaving yourself open for downcoding is by including vague descriptions of body parts in your doctor’s physical exam documentation.

The problem: Many doctors will write “abdomen” instead of “gastrointestinal tract” or even just “GI.” The patient’s abdomen isn’t an organ system for purposes of the physical exam portion of the E/M visit, but the GI tract is, say experts. So your doctor may lose credit for examining the patient’s GI tract. At the very least, it doesn’t sound as if your doctor performed a thorough examination of the GI tract.

Also, many doctors will write “head” when they examined the patient’s eyes as well as the patient’s ear, nose and throat. Eyes count as one organ system, and so do ENT, say experts. But if the doctor merely writes “head,” he or she will receive credit for one body part instead of two organ systems--or no credit at all.

“If they’re supposed to be documenting organ systems and they’re documenting body sites,” then auditors will knock those claims down, warns Jo Ann Steigerwald, a senior consultant with the Wellington Group in Cleveland, OH. Carrier auditors as well as the Comprehensive Error Rate Testing contractor will be looking for documentation that doesn’t support the level of service you claimed.

Best practice: Some coders will go ahead and amend the documentation to say “GI tract” if the doctor wrote “abdomen,” says Quin Buechner with ProActive Consultants in Cumberland, WI. But the carrier auditor can still look back and see that the doctor originally wrote “abdomen,” and they may choose to downcode the claim. It’s better to educate your doctor, Buechner adds.

Tip: You should use a template to make sure your doctor documents the correct organ systems instead of body parts, advises Steigerwald. This can be a paper checklist or an electronic record.