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Is your documentation up to par?

July 2008

Published in the July 2008 issue of Today’s Hospitalist

WHEN IT COMES TO SELECTING the service code that hospitals use to bill insurers, it’s been my experience that hospitalists typically choose the appropriate level of service for the presenting problem and risk. The problem is that all too often, hospitalists’ documentation doesn’t support that level of service.

As I’ve said before in this column, insufficient documentation can come back to haunt you if a payer ever reviews your records to justify a claim, or if you’re audited. That’s why it’s important to understand what documentation you need to provide to support your code choice.

This month, I’ll review the three components you need to document with every service: history, exam and medical decision-making. You must document all of those components whether you’re billing a consultation, an admission or a subsequent visit.

The history is especially important when it comes to billing admissions. Unless you’re billing a level one admission, you need to provide a comprehensive history.

When documenting a patient history, you must supply information about the following four elements:

1. Chief compliant. Always state your reason for seeing the patient, especially when documenting a subsequent visit. One of the most common documentation errors I see when documenting subsequent visits is simply stating “follow-up.”

You must instead be specific. Document “follow-up hypertension,” for example, even if you have documented a previous note for a different date of service on the same page. Your note for every date of service must state the reason for the visit.

2. History of present illness. Get in the habit of documenting four elements of the history of present illness, such as location, duration, timing, and signs and symptoms. This will help you meet the history of present illness documentation requirements for any level of service.

3. Review of systems. For consults and admits, document that you’ve reviewed at least 10 different systems. If you’re providing any level of a subsequent visit, you’ll be covered if you document that you’ve reviewed two systems. Using the blanket statement “all other systems reviewed are negative or WNL” (within normal limits) is acceptable and will ensure that you get credit for a comprehensive review. But remember that you can use this statement only after you’ve performed a complete review of systems and documented all individual and pertinent positive and negative responses.


4. Past medical, family and social history. For consults and admits, you need to document a past medical, family and social history. That documentation is not required for subsequent visits.

If you can’t obtain a history for patients “individuals who are intubated or comatose “you need to document that “the history was unobtainable due to “¦” and then state the reason. Simply noting that “history was unobtainable” will not suffice.

Documenting the exam is pretty straightforward. For any level of admit or consult, documentation showing that you’ve examined eight organ systems will cover you. For subsequent visits, the general consensus is that documenting an examination of at least five body areas will cover you for any level of service.

Keep in mind that you must include a statement for each body area or organ system in your exam that has a positive or abnormal finding. (You also need to document each individual area or organ system examined that has no relevant findings.) Don’t use the caveat “all others negative” in the exam portion of your documentation.

Medical decision-making
Documenting decision-making is more complex than documenting history or exam. That’s because the record accurately needs to reflect the complexity of your decision-making and your management options.

When documenting medical decision-making, you need to cover two of the following components:

  • number of diagnoses and management options;
  • amount and/or complexity of data; and
  • risk.

To make sure that your record of decision-making supports your code choice, here’s a list of what you can claim credit for in your documentation:

  • established problems that are stable but may affect patient care;
  • problem(s) that are worsening;
  • additional work-up, such as labs, X-rays or medical tests;
  • ordering or reviewing labs, X-rays or medical tests;
  • discussing tests with a performing physician, such as talking with a pathologist about an abnormal test result;
  • obtaining history from other sources such as an interpreter, family member or caregiver; and
  • the use of independent visualization, such as interpreting an X-ray yourself.

The key to successfully documenting decision-making is to note the routine things you consider when caring for a patient. You can help paint a picture of the complexity of illness by noting any underlying condition(s) that affect the patient and the diagnoses that you have considered or ruled out. What you want to document is the thought process you use to arrive at a diagnosis or management plan.

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.