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Improving Clinical Documentation
By Peggy Stilley, CPC, CPMA

The written word can be very powerful—and medical documentation is no exception. Medical records provide valuable information to assist patient care by detailing current illnesses, previous conditions, treatment options, medications, tests, and services performed, among other items. Medical record documentation is a matter of compliance and good patient care. It helps determine CPT codes to support reimbursement and identifies medical necessity for services being performed.

The first step to improving clinical documentation is identifying a potential deficiency and being willing to take corrective measures. This can be accomplished by auditing medical records, either internally or by an outside entity. Providers can conduct prepayment audits (before a claim is filed) or retrospective audits (after a claim is filed and reimbursed) or focus on a specific procedure or code. Audits can be performed using payer-specific criteria or by selecting codes/procedures from a utilization report.

The second step in the process is communicating an audit’s findings to the records’ authors. Providers cannot improve documentation when details of deficiencies are not made known. Be specific with the changes necessary to meet established guidelines. The findings should be conveyed with citations from official sources as well as contain an explanation of the documentation required to support the service. Lack of documentation can often be addressed by educating doctors about the requirements. Some audit findings may result in adjustments to practice policies. Audit findings are occasionally the result of an EMR inefficiency or misstep in implementation—for example, when a physician selects the appropriate template for a “new” or “established” patient but the wording does not print on the document. When looking at a single date of service, it is not always able to discern whether a patient is new or established.

Develop a process for communicating with providers when documentation does not support the service being reported. Documentation improvement does not occur without communication—you can’t fix what you don’t know is broken. The method of communication can be key. Address specifics with providers and explain what is lacking in the documentation. Examples include the following:

Example 1
Finding: A physician is billing a high-level visit for a new patient. History elements require one pertinent statement from each area of personal, family, and social history. Lack of documentation from any one of these three areas would result in a lower level of service regardless of the extent of the exam and overall care to the patient.

Recommendation: Examine the method of collecting the patient’s medical history. (Does the patient complete a history form? Is the information imported into the EMR? Does the provider utilize a template?) Then determine how the method can be improved to assist the provider in capturing the necessary information.

Example 2
Finding: Documentation includes a list of chronic conditions or diagnoses for which the patient has or is being treated; however, it is not clear if the condition affects the reason for the current encounter.

Recommendation: The primary diagnosis should reflect the chief complaint, with additional diagnoses that affect the clinical picture also reported. The correlation must be drawn in the assessment and plan describing the effect on the current condition being treated. The provider’s cognitive thinking must be present in the documentation.

Documentation tells a story—and good documentation should provide a complete image of the care provided on that encounter. The history should detail where and how it occurred, when it started, the severity of symptoms, what might change the symptoms, etc. The exam should include, at minimum, any system or area directly affected by the symptoms. Any ancillary services (lab, x-ray, etc) should be documented and support the reason for ordering the test, and the assessment and plan should include the differential diagnosis.

While “rule out” and “I suspect” cannot be used as diagnoses, they certainly tell the story of what a physician is thinking and support the complexity of an encounter. For example: 9-year-old with abdominal pain—could be viral in nature, but with positive exam and history cannot rule out possible appendicitis.

Peggy Stilley, CPC, CPMA, is the director of audit services for AAPC Physician Services.