Nail Down Documentation from a Provider’s Perspective

Posted on 9 Feb, 2018 |comments_icon 0|By Elizabeth

Many physicians are facing burnout as they struggle to keep pace with the ever-evolving practice of medicine. This inherent resistance to change and process improvements makes a coder’s job much harder.

While in their first year at medical school, providers are trained to write a beautiful note; by the time they are in their internship, they are told to hurry up. Time is of the essence, and documentation inadvertently takes a back seat.

Physicians are not trained to document to make the coder’s job easier (unless they receive on-the-job instruction) and often don’t have time to substantiate to the level of specificity necessary to obtain full reimbursement.

Key: The approach for coders to take is to recommend that providers make small documentation changes that help support a higher level of service when it occurs to ensure appropriate payment.

Avoid Documentation Disconnect

Caution: A provider performs an examination and wants to bill 99204, Office or other outpatient visit for the evaluation and management of a new patient. Code 99204 requires the fulfillment of three main components: that a comprehensive history be taken, followed by a comprehensive examination, and MDM of moderate complexity.

However, based on the brief documentation provided, the coder can only bill 99202, also described as Office or other outpatient visit for the evaluation and management of a new patient …, but requiring only an expanded problem-focused history and examination and straightforward decision making. Regardless of what occurred in the exam room, a coder can only recoup what the record can substantiate.

Bright Idea: Coders and practice managers can use examples of incorrect or insufficient documentation as opportunities for training providers. Instruction should be tailored toward specific questions or areas of concern, either in one-on-one personal sessions or via large-scale, continuing education seminars, followed up with handout resources that practitioners may easily consult for reminders.

Tip: Consider laminating these CDI resources, or offering them in a well-labelled binder with sheet protectors, to increase the likelihood of their long-term retention. Anything you can do to give your physicians easy and convenient access to references puts you ahead of the game. You also send a message to your clinical team that you’re doing your best to simplify and streamline the process.

Top Tip: Conduct monthly documentation audits, starting with a few charts per provider. A regular routine of random checks helps practices get in sync with audit requirements, while identifying holes in EMR record-keeping.

Plus: Such habitual simulated procedures allow practice managers to observe faults and weaknesses – heading problems off at the pass. A system of monthly audits can help practices avoid the pitfalls that tend to overwhelm most unprepared clinics.


Connect the Documentation Dots to Revenue Outcomes

Linking provider record-keeping to incoming revenue streams is a great feedback mechanism for motivating disinterested providers. If the physician is providing improved documentation, and there is a spike in the revenue received, the coders or practice manager should let the physician know and express their appreciation. Seeing tangible proof of increased revenue underscores to the physician the value of his effort and enhances your credibility, as well.

Bright Idea: On the flip side, if the coder has issues with the provider’s documentation and revenue is dipping because of it, the coder should let the provider know. Requests for extra effort and improvement will carry more weight if you support your concerns with hard evidence, such as a drop in revenue.

Don’t Dig for Details

Providers must appraise not just evaluation and management (E/M) documentation, but also procedural notes. These records serve to account for procedures which occurred and were performed during a particular encounter, like a surgery.

Providers are expected to thoroughly detail the events of encounter, including the date and time, the outcome, and anything unexpected that may have happened and how the care team responded to the crisis. These procedural notes are especially important because faulty or incomplete documentation often results in loss of revenue.

Even if it is implicitly understood by everyone on the care team that a certain procedure always occurs in the operating room during a certain other documented procedure, a coder is still limited to billing only for those services specifically mentioned in the record as having been performed on the patient.

Caution: Auditors for payers neither make inferences into care provided but not documented in the provider’s charts, nor do they code for treatment. If a piece of requisite documentation is not there, the auditor will be justified in arguing that the procedure never happened. It’s in the payer’s best interest to save money, but that doesn’t mean the provider has to make it easy on them by neglecting to document correctly.

Learn More

Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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