To bill or not to bill: missing documentation question

Kristen Bensel

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Pilot rock, OR
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This is probably going to sound like a pretty obvious question, but I am really starting to struggle with this after discussions with my coworkers on code assignment.

When I was first starting out as a coder, I was taught that when documentation points for a procedure are missing from a note that it is inappropriate to bill for the service, and also inappropriate to have the provider addend the note with the missing documentation. It should be used as an educational moment for next time. I am now starting to question if this was just the process my lead followed or if this is actually how it should be.

For Example:

MR indicates the following documentation must be in the note to bill for excisional debridement CPT 11042 of a DM Ulcer:
Pre debridement measurements
Location and characteristic of wound
Type of tissue removed (eschar, fibrin, bone, etc.)
Depth of procedure
Amount of bleeding and how it was controlled
instrument used and size of the instrument
patient tolerance and pain control
dressing applied and treatment follow-up
Post debridement measurements

The provider only documents the post debridement measurements, the dressing applied, depth of the ulcer and location along with the instrument used. Can the provider be queried for the missing documentation to be addended to the note or not?

Or a patient comes in for DM nail care-

MR indicates the following documentation must be in the note to support the use of CPT 11721
Characteristics of nails (thick, discolored, painful, yellowed, crumbling)
Number of nails debrided
instrument used
outcome of the debridement (% of thickness resolved, pain resolved, etc.)

Provider documents the characteristics of the nails & number of nails debrided. Is it appropriate to have the provider addend the note with the missing documentation?

This is an ongoing issue I have with some providers in the clinic I work at. These providers know the documentation that needs to be there, but never get it all in the note, and they tend to feel that my guidance is just my personal coder preference. So any thoughts you all might have on this are greatly appreciated.
 

csperoni

True Blue
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Selden
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Disclaimer: Not legal or compliance advice. ;)
I personally will allow a provider to occasionally make an addendum and still bill for the procedure. I do use it as a teaching tool as well, explaining that if it occurs in the future, it may not be billable.
It shouldn't be chronic underdocumenters making addendums weeks after service.
Example:
Yesterday, clinician forgot to check the EMR box to order a sonogram, but in the note even mentions the findings. I would have no issue with the correction today, and then bill for the services. An occasional query I have no issue with, but not the same problem repeatedly.
Chronic underdocumenters are not only losing revenue, but also opening themselves to liability.
Depending on where you work, and the personalities of everyone involved, I would suggest the following possible options:
1) Especially if physicians are compensated in any way by wRVU or revenue, (benchmarks, bonuses, etc) - compile a 1 week list of what was not billable due to documentation issues. Explain to the provider they are giving away their services for free due to lack of documentation. Sometimes 5 more words is all it needs.
2) Some practices do very well with scribes. Worth the cost per hour to be able to bill all services.
3) Some clinicians prefer dication. Again, worth the cost to bill for everything provided.
4) Show the potential lost revenue to someone up higher on the financial ladder.
5) Again, depending on personalities, host either group or individual educational sessions. Make it weekly, monthly or as needed.
6) Involve compliance if the documentation is very shoddy and all other efforts have failed.
In some settings, the biller/clinician relationship is very collaborative. In others, not so much. I vastly prefer the collaborative option, and adjust my suggestions/education based on the clinician. They don't teach coding in medical school. Sometimes you just have a clinician that is not aware of the whole picture. Being a physician is vastly different than getting paid to be a physician.
My philosophy is that coders are there to support the clinicians and to allow doctors to practice medicine, not follow the latest AAPC post. 🙋‍♀️ In order to allow doctors to be doctors, the practice needs to function financially. Very few of us can afford to give away our services for free. Anything I can do to help, educate, and assist my clinicians about what is needed (including gentle reminders) in order to not provide free services I will do. I am not above bribes with chocolate or tacos.
All that said, there are some clinicians (just like every other profession in the world) that are stubborn, or arrogant, or lazy, or whatever that will not change their ways. I have been fortunate enough in my career to rarely encounter this. But I would still try.
Good luck!
 

Kristen Bensel

Networker
Messages
57
Location
Pilot rock, OR
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0
Disclaimer: Not legal or compliance advice. ;)
I personally will allow a provider to occasionally make an addendum and still bill for the procedure. I do use it as a teaching tool as well, explaining that if it occurs in the future, it may not be billable.
It shouldn't be chronic underdocumenters making addendums weeks after service.
Example:
Yesterday, clinician forgot to check the EMR box to order a sonogram, but in the note even mentions the findings. I would have no issue with the correction today, and then bill for the services. An occasional query I have no issue with, but not the same problem repeatedly.
Chronic underdocumenters are not only losing revenue, but also opening themselves to liability.
Depending on where you work, and the personalities of everyone involved, I would suggest the following possible options:
1) Especially if physicians are compensated in any way by wRVU or revenue, (benchmarks, bonuses, etc) - compile a 1 week list of what was not billable due to documentation issues. Explain to the provider they are giving away their services for free due to lack of documentation. Sometimes 5 more words is all it needs.
2) Some practices do very well with scribes. Worth the cost per hour to be able to bill all services.
3) Some clinicians prefer dication. Again, worth the cost to bill for everything provided.
4) Show the potential lost revenue to someone up higher on the financial ladder.
5) Again, depending on personalities, host either group or individual educational sessions. Make it weekly, monthly or as needed.
6) Involve compliance if the documentation is very shoddy and all other efforts have failed.
In some settings, the biller/clinician relationship is very collaborative. In others, not so much. I vastly prefer the collaborative option, and adjust my suggestions/education based on the clinician. They don't teach coding in medical school. Sometimes you just have a clinician that is not aware of the whole picture. Being a physician is vastly different than getting paid to be a physician.
My philosophy is that coders are there to support the clinicians and to allow doctors to practice medicine, not follow the latest AAPC post. 🙋‍♀️ In order to allow doctors to be doctors, the practice needs to function financially. Very few of us can afford to give away our services for free. Anything I can do to help, educate, and assist my clinicians about what is needed (including gentle reminders) in order to not provide free services I will do. I am not above bribes with chocolate or tacos.
All that said, there are some clinicians (just like every other profession in the world) that are stubborn, or arrogant, or lazy, or whatever that will not change their ways. I have been fortunate enough in my career to rarely encounter this. But I would still try.
Good luck!


Christine Thank you!!! Sadly, a lot of this has already happened with these particular chronic offenders. I will discuss this further with my Supervisor and CFO. Thank you so much for your response!
 

carolhodge

Networker
Messages
71
Location
Richmond Hill, Georgia
Best answers
0
Disclaimer: Not legal or compliance advice. ;)
I personally will allow a provider to occasionally make an addendum and still bill for the procedure. I do use it as a teaching tool as well, explaining that if it occurs in the future, it may not be billable.
It shouldn't be chronic underdocumenters making addendums weeks after service.
Example:
Yesterday, clinician forgot to check the EMR box to order a sonogram, but in the note even mentions the findings. I would have no issue with the correction today, and then bill for the services. An occasional query I have no issue with, but not the same problem repeatedly.
Chronic underdocumenters are not only losing revenue, but also opening themselves to liability.
Depending on where you work, and the personalities of everyone involved, I would suggest the following possible options:
1) Especially if physicians are compensated in any way by wRVU or revenue, (benchmarks, bonuses, etc) - compile a 1 week list of what was not billable due to documentation issues. Explain to the provider they are giving away their services for free due to lack of documentation. Sometimes 5 more words is all it needs.
2) Some practices do very well with scribes. Worth the cost per hour to be able to bill all services.
3) Some clinicians prefer dication. Again, worth the cost to bill for everything provided.
4) Show the potential lost revenue to someone up higher on the financial ladder.
5) Again, depending on personalities, host either group or individual educational sessions. Make it weekly, monthly or as needed.
6) Involve compliance if the documentation is very shoddy and all other efforts have failed.
In some settings, the biller/clinician relationship is very collaborative. In others, not so much. I vastly prefer the collaborative option, and adjust my suggestions/education based on the clinician. They don't teach coding in medical school. Sometimes you just have a clinician that is not aware of the whole picture. Being a physician is vastly different than getting paid to be a physician.
My philosophy is that coders are there to support the clinicians and to allow doctors to practice medicine, not follow the latest AAPC post. 🙋‍♀️ In order to allow doctors to be doctors, the practice needs to function financially. Very few of us can afford to give away our services for free. Anything I can do to help, educate, and assist my clinicians about what is needed (including gentle reminders) in order to not provide free services I will do. I am not above bribes with chocolate or tacos.
All that said, there are some clinicians (just like every other profession in the world) that are stubborn, or arrogant, or lazy, or whatever that will not change their ways. I have been fortunate enough in my career to rarely encounter this. But I would still try.
Good luck!
What a great response!! I'm keeping this for future reference.
 
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