Wiki E/M time based coding

[Greenpiper]

Issue: some of our providers have started using time consistently to document their charts. They are using a canned statement "I have spent a total of XX minutes face to face with the patient, reviewing past documentation, managing labs/xray orders, coordinating with other healthcare professionals and / or documenting today's encounter." No where in the chart is there supporting documentation for the activities listed in the canned statement and most are recording 45+ minutes (approx. 90%+). We have been instructed to code based on the time provider supplies as "It is on the provider to support in an audit situation that they were actually in the pts chart for xx time. The legality falls to the provider not the coder." Having a hard time with this as I feel like coders WOULD be responsible for knowingly coding the chart incorrectly? Maybe we are over thinking this issue but I have not been able to find anything definitive discussing this. What would an auditor be looking for in these cases?

1. Urinary incontinence, unspecified type (Primary)
Assessment & Plan:
Patient presents with complaints of urinary incontinence. No lumbar injuries or factors back pain. No trauma.
Plan
-Urine dipstick
-Urine culture
Orders:
- POCT Urinalysis Dipstick Non-Automated
- Culture, Urine, Comprehensive; Future
- XR Lumbar Spine 2 - 3 Vw
2. Chronic pain of left knee
Assessment & Plan:
Patient presents with chronic left knee pain. Patient feels her knee gives out especially walking downhill. Patient has less difficulty walking up or. No trauma or injuries to her left knee. Patient is using a wheel walker for ambulation. This is her baseline.
Plan
-Left knee x-ray
-Possible physical therapy referral
Orders:
- XR Knee Left 1 - 2 Vw
I have spent a total of 45 minutes face to face with the patient, reviewing past documentation, managing labs/xray orders, coordinating with other healthcare professionals and / or documenting today's encounter.

Orders Placed
POCT Urinalysis Dipstick Non-Automated
Culture, Urine, Comprehensive
XR Knee Left 1 - 2 Vw
XR Lumbar Spine 2 - 3 Vw
All Encounter Results

Medication Changes
None
Medication List

Visit Diagnoses
Urinary incontinence, unspecified type R32
Chronic pain of left knee M25.562, G89.29

 

[kdlberg]

If I were auditing your providers and saw this exact same statement after 5 or so charts, I would wonder if they actually did the work. By the time I get to the 15th chart, I see the first few words and don't even bother to read the rest.

Canned statements are a good starting point but they need to be adjusted to what was done at that visit. If they coordinated with another provider, who was it and what was coordinated? Reviewing old records--what was found? If nothing clinically relevant was found, state that. Was an exam done? Counseling and education, what did you talk about? It doesn't have to be a novel, something like "counseled on DASH diet, start on moderate exercise 2x week" is sufficient.

 

[csperoni]

I have a few issues with the time statement as written.
1) And/or. To me "and/or" means the provider could have done one of those activities or all of those activities. 45 minutes for all is "less suspicious" than taking 45 minutes doing one of those items. "and/or" should be replaced with "and" along with the provider REMOVING any phrases for activities not done for this encounter.
2) Face to face with patient. It is not only face to face time. You may count the specific encounter related activities the same day as the encounter. This statement doesn't state what day those potential activities were performed.
3) If there is a separately billed procedure or test, the time spent on that other billed item cannot be counted. The statement as worded does not state this.
If they can't accurately use templates or templated statements to customize for this specific encounter, they should not be using them at all.

I agree with @kdlberg above. One note with a specific statement is not suspicious. 20 notes with the same exact statement and same exact time raises an eyebrow. Like really - not a single patient was 44 minutes, or 48 minutes? All exactly 45? The UTI follow up without any additional complications took exactly the same time as the patient with uncontrolled diabetes and had a stroke a month ago?

All that being said, I do not expect all coders to be part of the compliance team. If my team has 70-80 charts each that day, I do not expect them to do a full audit level review on all documentation. At some point, you have to trust that the signed medical record is accurate. Items that are blatantly incorrect or unclear are sent back for query. A "suspicious" trend on a provider's notes gets a reminder about accurate documentation. I don't see how someone could legally hold a coder responsible for a provider's documentation - they didn't provide care, they weren't present for the visit, they didn't document, they didn't sign the documentation.

 

[Greenpiper]

Thank you both for your responses. We are feeling the same and are addressing this with our providers and upper management.