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I am currently working with our general surgery group to implement the EMR. I am reviewing some notes to insure that the doctor has capture all the components required for documentation of the E/M service. What I have found is that he is not only capturing everything there is more than what I would deem necessary.

Since these patient's are seeing him for a specific problem does it seem unreasonable for him to have a complete exam ('95 Guidelines) and more for each patient. In my mind this is could be a red flag. With that said, I am cautiously approaching him to streamline is documentation process, because I don't want to end up with very little documentation.

Here is an example:
Patient presents to office with a cyst on his left shoulder. He is a new patient. History codes out to EPF, since the HPI is brief. The exam however is comprehensive with 13 systems documented in depth. In my opinion many of the areas examined were unnecessary, but I am not sure how other auditors would view this. The MDM was moderate. Incision and drainage was planned for a future date.

I in no way want to question his clinical judgement, but I also do not want his overly extensive notes to come into question in an outside audit. Now is the time to refine his documentation.
Milwaukee WI
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Medical Necessity

This is a problem I see with EMR as well. I think we are all somehow hardwired to "fill in all the blanks" when presented with a format that specifically asks us about each area. So, the physician, faced with an exam template that specifically asks for Const, Skin, Eyes, ENT, Resp, CV, etc ... will start filling out each section.

This is a new patient and you only have an EPF history, so you won't get any higher than a 99202 anyway.

Could the physician be thinking that since this was a new patient he HAD to perform a full work-up? (i.e. a comprehensive physicial / preventive exam)

You want to help your physician not waste time performing/documenting services that aren't medically necessary. But you need to understand his/her thinking with respect to those NEW patients.

Hope that helps.

F Tessa Bartels, CPC, CEMC


Local Chapter Officer
Raymore, Missouri
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I have worked with gen surg for quite a few years now, and this has always been the case- even before EMR. One reason is that if this patient will be needing surgery, then the hospital will require an H&P, and so this note will serve as that as well.

If I were going to do surgery on someone I would certainly want to know as much about them health-wise as possible. General Surgeons are generally very thurough, and justifuably so.

NOW, does that mean they get a level 4 or 5 everytime- absolutely not. They should not be coding on the amount of documentation. The surgeons need to know that there should be some balance.