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Common documentation errors

November 2012
Choosing codes for incisions and codes for incision and drainage procedures

Published in the November 2012 issue of Today’s Hospitalist.

OVER THE YEARS that I have spent reviewing documentation for hospitalist groups, I”ve reached this conclusion: Physicians everywhere tend to make the same handful of documentation mistakes. Getting your documentation right makes a big difference in terms of supporting a certain coding level and how much you’ll be reimbursed. Here are some common documentation errors “and some tips for fixes.

Skimping on admission history
Probably the trickiest area for hospitalists is the history component for both initial hospital care (99221-99223) and initial observation services (99218-99220, 99234-99236). That’s because you have to meet requirements in three areas: history of present illness, review of systems, and past, family and social history. Skimping on any of these three areas can be costly because the number of relative value units included in a level-three initial hospital visit (99223) is almost twice that of a level one (99221).

Both initial hospital care and observation codes require a detailed to comprehensive history. But a detailed history counts only toward the lowest coding level, which is rarely the one hospitalists intend to support.

Two common history errors “one in history of present illness, the other in past, family and social history “take what may have really been a comprehensive history and bust it down to only a detailed one.


  • History of present illness:

Are you detailing past history instead of the history of the present illness that warranted the admission? I often see a very lengthy history, but it’s mainly about past admissions, ED visits and the patient’s chronic problems. You get credit for documenting past history, but not in the history of present illness. Instead, give details of current problems or symptoms that do count toward history of present illness, such as severity, timing or duration.



  • Past, family and social history:

Are you still stating “noncontributory” as part of your past, family or social history? If so, you’re probably not being given credit for that history portion.


As many times as we address this issue, I still see “noncontributory” being used. Auditors tend to not apply it toward any higher coding level because you are not clearly indicating whether you asked about past history or if you just thought it didn’t contribute to the present condition.

Remove “noncontributory” from your documentation vocabulary. If you don’t think past, family and social history is a factor in the patient’s current condition, then document that you asked about it and your findings were negative.

The problem with body areas
Does your exam documentation include elements that you won’t receive credit for?

As I mentioned, you need to do a comprehensive exam to bill level-two and level-three observation or initial hospital care codes, and that exam must cover eight “organ systems.” Body areas, however, don’t count toward a comprehensive exam. So if you document eight elements but one is the “head, normal cephalic,” you have just down-coded yourself to a detailed exam. That’s because you have documented only seven organ systems and one body area.

The extremities and neck are other problematic exam areas, and comments about them usually apply to the cardiovascular, musculoskeletal or skin organ system. Auditors can count each system only once, regardless of how it’s labeled, so documenting “extremities “no edema” could count as a cardiovascular exam. But if you already covered that system by documenting heart auscultation, an auditor won’t give you credit for examining extremities.

Use organ systems, not body areas, to label required elements in a comprehensive exam. Document “GI” instead of “abdomen,” “musculoskeletal” instead of “back,” “lymph” instead of “neck,” etc. Then make sure you document examining at least eight systems.

Diagnosis: not enough documentation
In terms of diagnosis and medical management, are your notations too simple, such as “continue meds” in your assessment and plan?

When you’re following up on a complex patient, you need to include details to indicate when a patient’s problem is severe, not responding to treatment or getting worse. Otherwise, you may fall short in supporting your true level of medical decision-making when it comes to diagnosis and management.

Your assessment and plan is a good place to paint the clinical picture, and it’s important to document your thought processes to support the level of care you choose. Key indicators include details of how the patient is responding, such as “worsening,” “uncontrolled,” “stable” or “improving.” (Stable problems are usually less complex in terms of medical decision-making than ones that are getting worse.)

Be sure to document new complaints or symptoms to demonstrate decision-making complexity and help support a higher level of service. And instead of putting “continue meds,” comment on the patient’s status “”improving,” “stable,” “worsening” or “critical” “or response to treatment.

Counseling, coordination of care errors
Do you document how long you spent counseling the patient but fail to state how long the entire visit lasted?

According to counseling and coordination of care guidelines, you must devote more than half of a visit to counseling or care coordination. But simply noting that “30 minutes were spent in counseling” provides only part of the necessary information. Because it’s not clear how long the visit lasted, you can’t determine whether more than half was spent on counseling. Instead, state “Total visit time XX minutes, total counseling time XX minutes,” and include a summary of the counseling.

Time problems on discharge
Does your documentation reflect when you spend more than 30 minutes on a discharge? One of the two hospital discharge codes “99238 “has no time threshold requirement. But 99239, which is for hospital discharge “greater than 30 minutes,” does.

When auditing records, I often find that doctors want to bill 99239 for a discharge, but then fail to document how much time they spent in discharge services. To receive the higher reimbursement associated with 99239, document your entire time spent doing the discharge and indicate that it was at least 31 minutes.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.