Using Documentation Templates? Read This First
Published on Wed Aug 13, 2003
You have to base your ICD-9 Coding on your physician's documentation, but that doesn't mean you have to accept your physician's form of documentation. Documentation templates may seem like a coding dream come true, but if your diagnosis codes are looking eerily familiar, you may be basing your coding on "cloned documentation" - a coding and compliance nightmare.
If your documentation template allows your physician to check one box for "yes" and another for "no," and it's not individualized for each system, you're at risk of coding from cloned documentation, says Melissa DePasquale, CPC, CCS-P, CHCC, director of coding and compliance for Community Care Physicians in Latham, NY. What to Look For Use this example to help you distinguish whether your templates are resulting in identical diagnosis codes and documentation for patients with different conditions.
On Tuesday morning, a patient presents to the urologist complaining that she is unable to hold her bladder when doing physical activity. The urologist, in filling out the patient's form, checks a box for urinary incontinence. Later that afternoon, a different patient presents also complaining of the inability to control urination when the urge to urinate first occurs. Once again, the urologist checks the same box. Both patients' charts are submitted to the coding and billing department, and the coder assigns both patients an office visit code of CPT 99212 (Established patient office visit) linked to the "not otherwise specified" incontinence code ICD-9 788.30.
The patients presented with different manifestations of the condition, however, and the diagnosis code for the first patient should have been 625.6 (Stress incontinence, female), while the correct diagnosis code for the second patient was actually 788.31 (Urge incontinence).
According to a September 2002 "Medicare Sentinel" publication by TrailBlazer Health Enterprises LLC (a Virginia carrier), "One of the probe reviews found several physicians whose office records indicated they used a computerized documentation program that 'defaults' information from previous entries to successive progress notes." The carrier goes on to explain that the default information produced documentation that was identical for multiple patients' physical exams.
Cigna Medicare reinforces the dangers of medical record cloning and tells coders what proper documentation should look like. Cigna states in a Medicare Bulletin that "All documentation in the medical record should be patient-specific. Cloning of documentation will be considered misrepresentation of the medical-necessity requirements for coverage of services." According to Cigna, you will be denied reimbursement if the carrier discovers cloned documentation.
But don't assume you can never have patients with similar diagnosis codes on separate claims forms - that's fine as long as the patients [...]
