Wiki Only drawings for exam findings, is it billable?

[tamphamh]

We have a doctor who is adamant about not using EHR. And, yay!, he finally agreed to do it!

He does not have time to verbalize his findings, however, due to the volume of his clinic. He is currently drawing all of his findings in a paper chart.

We were able to find a way for his scribe to document the Impression/Plans in the EHR, but they couldn't keep up with documenting all of the findings (he's a retina specialist), and he still prefers to draw them all.

My question is, can we submit the claim if we make sure the drawings is attached to the note, along with documentation of impressions and plans?

 

[Cheezum51]

All I can say about this is: Really? So he has the time to draw his findings but doesn't have the time to verbalize them so a scribe can document them in the EHR? I'd love to see some of those drawings. Having seen records of a retinal specialist in my area who did drawings of his retinal findings which were basically one step above what a child could do with stick figure drawings, I can't imagine how those could ever be used in defense of a malpractice lawsuit. What about the CC/HPI to show the medical necessity for the exam or the various exam elements? How is that recorded?

How is the scribe documenting the Impression/Plan? Are they "interpreting" the drawings in some way without the doctor verbalizing the I/P to them? I don't see how that would be legal.

Personally, I can't imagine how what you're proposing would pass any level of payer audit and can imagine the practice having to pay out lots of money when the insurer recoups their fees.

If the doctor isn't taking time to verbalize the findings, does he take any time to speak with the patients about those and their plan of treatment?

I'm not trying to be snarky but I can't imagine how this doctor got through their training doing that type of "documentation>"

Waiting to see what others have to say about this. All I'm seeing is a big red flag.

Tom Cheezum, OD, CPC, COPC

 

[lgardner]

I agree with Dr. Cheezum.

This seems extremely non compliant with documentation guidelines and regulations.

 

[tamphamh]

Dr. Cheezum and Igardner:

Thank you for sharing your thoughts on this matter. I appreciate your concern for the legal and practical aspects of using drawings for documentation. The doctor in question may have their own reasons for using drawings, but I agree that it's important to ensure that all necessary information is being accurately recorded. It's also important to consider how these records might hold up in a malpractice lawsuit or payer audit.

Because the doctor still wishes to draw, I believe he must properly label the drawings in order for them to be considered proper documentation. Concerning documentation of the Impression and Plan, the doctor will actually tell them the Dx/Code to use, the OCT interpretation, and the follow-up plan - which he has been doing anyway. He didn't have time to verbalize findings because he prefers to spend most of his time in the room talking and explaining to the patient. He always has long conversations with them, not only about their condition but also about personal matters, which makes it difficult for the scribe to pick up on what he says. It's even more difficult for the scribe to keep up with him because he refuses to change his way of seeing patients. He has been practicing for almost 40 years so it's very difficult for both him and the staff unfortunately.

I'm also interested in hearing what others have to say about this topic and any potential solutions they might offer. Thank you again for your response and for engaging in this discussion.