How many times have you heard this phrase: If you didn’t chart it, you didn’t do it? I would imagine more times than you can count. For so many years, your physicians had to write out their office notes. Even when they dictated their notes you needed to remind them to include everything that was performed in the office. If your physician spoke to the patient on the telephone, they needed to document the conversation. It has always been a challenge to get physicians to document everything that they said or did.

One would think that with electronic health records, it would be easier for physicians to document what they do. After all, most practice management systems take the clinician from screen to screen. Each screen allows the physician to ask certain questions. Based on the questions asked, additional questions or topics would appear on the screen.

Frequently the physicians in the practice design the templates that ask the questions and gather the information. The practice management system would then recreate the information in a documented format. In fact, certain data automatically populates from visit to visit.

It should be easy; right? If it was easy and our physicians and clinicians used the systems completely and continued to document, our lives would be easier. However, that is not always the case. Physicians still need to ask the questions, they still need to document the patient’s responses and finally, they still need to follow the progression of questions. If the physician skips an area, or does not document the responses, then the documentation is not there for that visit or for future visits.

Poor documentation leads to improper coding and charging and incomplete or inaccurate billing. Many EHR systems offer a suggestion as to the E&M code that should be used based on the documentation, bullet points and often time. When a physician walks out of the patient exam room and knows that he had an intermediate visit with the patient, he must be able to justify charging that code and fee prior to billing. Too many insurance companies are now requesting documentation to prove that the level was in fact an intermediate visit.

That is the case recently for a physician. He billed a worker’s compensation carrier for a complex follow up visit using the procedure code 99215. The carrier asked for the visit note which the office sent. The carrier down-coded the visit to a 99213 based on the office visit note. The physician must now decide whether to accept the payment on the new code or add an addendum to his chart note including enough information to justify the original 99215 procedure code and fee.

In cases where comprehensive or complex visits are warranted, it is even more important to justify the charges through documentation. Unfortunately, insurance companies don’t always take the physician’s word that the visit was complex. Not only does the insurance company request the documentation, they down-code the visit and pay on a lesser E&M code.

This is also true of procedures that are done in the office. It does not matter whether the procedure is a simple clearing of the wax in a patient’s ear, a suture or a more complex procedure. If the procedure is not documented accurately in the chart, a charge can’t be generated whether the procedure was done or not.

As we move to ICD-10 coding, it will be even more essential to document every aspect of the visit and/or procedure. There will be an expectation of more precise coding and that coding may need justification.

As a practice it is important to:

·      Have all clinical staff trained as to the importance of documentation

·      Remind the physician that coding is based on the documentation as well as time

·      Assign a person in your office to periodically review the charts of all physicians to insure that the documentation matches the coding

·      Review operative and procedure reports to insure that all aspects of the procedures were coded

As time goes on and insurance companies continue to look for ways to save money, they will also continue to look for ways to deny or down-code procedures. It will be up to the physicians and coders to prove the procedure matches the visit history. The best way to do this is to document every step of the way, every aspect of the visit.

Having an electronic health record should make documentation more precise provided it is used in an appropriate way, inputting all the necessary information and asking the right questions. Some of the information only needs to be entered once and it transfers to all the visits (such as social history, family history and previous surgeries) while other information needs to be asked, monitored and added each time since it may change from visit to visit.

The rule of thumb in your office should be: if it is not written or charted, it was not done. Your coding and your reimbursements depend on it.