No Chart Left Behind

Years ago, I worked with a physician who was chronically behind in dictating his notes.  The charts were crammed into boxes by date, lining the walls of his office.  Sometimes, they flowed over into the hallway or into the break room.  This caused major inconveniences when a patient called for a lab result or returned for a visit.  I know you can picture this: the staff hurrying around the office with a list of charts for which they were searching, thumbing through the labels.  Inevitably, dictations were forgotten.  Could the doctor remember a week or two or three later what happened at the office visit?  He took handwritten notes and used them to jog his memory.  He said that worked.

 The boxes of charts were a visible reminder to him, to the staff and to administration of the problem.

 Today, unfinished charts can be all but invisible unless someone in the practice is running regular reports.  The clinician can see on her desktop or task bar the number of open notes, messages, reports to review and prescription renewals needed.  (Take your eyes off the task bar to see a few patients and the number of tasks in the queue explodes).  Medical practices need two things to prevent the modern day equivalent of boxes of charts lining the walls: regular and consistent monitoring and a policy on chart completion. 

 The practice leader should review the number of incomplete charts by clinician each week and monitor the age of those claims.  This will avoid unwelcome surprises like, “Do you know that we are holding hundreds of unbilled claims waiting for the charts to be finished?”

 As for policy:

 Medicare has no stated time policy about how soon after a service is performed on a Part B fee-for-service patient that it needs to be documented.  The Medicare Claims Processing Manual says only “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

  • We can probably all agree that “weeks later” is not “as soon as practicable after it is provided.”
  • Many groups suggest that visits are documented the same or next day, and mandate that all are documented within three days.
  • Consider a policy that for visits documented and closed after a certain time period (7 days? 14 days?) the physician won’t be given RVU credit.
  • There is no regulation in the Claims Processing Manual that states the visit must be documented before the claim is submitted.  Some groups have this policy in place.  In my opinion, I don’t think a group needs to hold claims unless there is a problem.  Most clinicians finish their notes in a reasonable period of time.   If the charge is submitted the day before the note is signed off, this isn’t a problem.  But, if there is a clinician who is regularly behind or who neglects to document for some visits, don’t submit claims until the documentation is complete.
  • Increased training on the EHR will often help a clinician to complete notes more quickly.  There are shortcuts in all systems, and some clinicians haven’t found them and haven’t been trained.  In groups of clinicians I often hear “Oh, don’t you know how to look that up from the visit page? You don’t have to open a new window….”
  • Consider allowing physicians to dictate into the HPI and comments into the assessment/plan section.  It adds value to the note.
  • Look at the schedule: is it optimal?

 Incomplete notes are a quality of care issue as well a compliance and billing issue.  Medical practices that find themselves in this situation need to address and solve the problems quickly.

Let’s trade: I’ll eat a peach if you’ll select a specific diagnosis code

When are two diagnosis codes better than one?  And when is one enough?

 Physicians get conflicting advice about how many diagnosis codes they should document and report.  When working in the hospital, Health Information tells them to document every sneeze, because hospital payment is often based on the severity of the patient’s condition and underlying medical problems.  In the office, most physicians are paid based on the CPT code and associated fee, and not on the diagnosis code.  However, more practices have risk based contracts that vary payment incentives based on the acuity of the practices panel of patients and Medicare’s shared savings programs will include acuity as one of the factors in its risk based incentive and payment programs.  This increases the importance of accurate and complete diagnosis coding on physician claims.

 Here are the guidelines for diagnosis coding for office/outpatient physician services:

  1. Use the ICD-9-CM codes that describe the patient’s diagnosis, symptom, complaint, condition, or problem.
  2. Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
  3. Assign codes to the highest level of specificity. Use the fourth and fifth digits when indicated as necessary in your ICD-9-CM volumes.
  4. Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that the services were provided for “rule out” purposes.
  5. Code a chronic condition as often as applicable to the patient’s treatment.
  6. Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions which no longer exist)

 Do not unbundle diagnosis codes, and don’t use two diagnosis codes when one is a symptom of the otherTwo heads are better than one, aren’t they?  So, two diagnosis codes must be better than one, too.  Not necessarily.  If the patient presents with joint pain, and tendonitis is diagnosed as the cause of the joint pain, use only tendonitis on the physician claim.  Joint pain is a symptom of the condition and would not be separately reported.  If the definitive diagnosis is known, use it without adding the symptoms of the condition.  If the definitive diagnosis is not known, code the symptoms.

Do not free text a few question marks in front of a diagnosis code and then select the code.   Such as this:  “?? Other venereal disease due to chlamydia trachomatis lower genitourinary sites 099.53.”  Doing this assigns the diagnosis to the patient.  Use the patient’s symptoms, if any. If the patient does not have symptoms, use a screening diagnosis such as V74.5 Screening examination for venereal disease.  Also, do not free text, “possible” “probable” or “rule out” in front of the diagnosis code in the electronic health record.  In many EHRs, this assigns the code that goes on the claim form.  Note the instructions, “Medical records, not claim forms, should reflect that the services were provided for “rule out” purposes.”

 Do assign underlying conditions if considered or assessed during the visit.  For example, a patient presents to General Surgery for gall bladder disease.  The patient’s underlying medical conditions include sleep apnea, diabetes and hypertension.   The surgeon wants a medical clearance before scheduling the surgery.  The surgeon is not treating the medical conditions, but these affect the surgeon’s treatment.  On the initial encounter, report the surgical condition in the first position and the medical conditions in the second and subsequent positions on the claim form. 

 Do or do not report underlying conditions?  ICD-9 instructions tell us to report those conditions that “coexist at the time of the visit that require or affect patient care or treatment.”  This instruction would tell us not to code conditions that were not assessed or which did not affect patient care.  However, many at risk or shared savings contracts base payments on the acuity level of the population of patients in the panel.  How does the payer know how sick the panel of patients is?  First, by analyzing the panel’s age and gender distribution.  Second, by the diagnosis codes submitted on claim forms.  If your practice is entering into those types of agreements, reporting underlying conditions is important. 

 Do select specific codes  You know how doctors tell their patients to exercise more and eat more fruits and vegetables, and we all ignore the advice?  We coders tell doctors to select more specific diagnosis codes, and the doctors all ignore our advice.  It’s a stalemate.  Perhaps we could trade: I’ll eat a peach if you’ll select a specific diagnosis code.    Specificity now will make the transition to ICD-10 much easier.  If your group will participate in any risk based contracts or shared savings programs, it is imperative that you accurately report diagnoses.

 Don’t tell anyone, but I’ve been a lazy diagnosis coder.  I knew that the practice would be paid the same amount if I reported one diagnosis code or four.  And, I knew the claim form (then) only allowed four diagnosis codes.  But, I’ve turned over a new leaf and have adopted a new attitude.  This old dog is learning new tricks.  Block that metaphor? 

Can’t I bill TCM for all discharged patients?

“I can bill all discharges with Transitional Care Management codes.  They’re all moderate complexity”

Recently, a client wrote to me about a physician who wants to use the Transitional Care Management (TCM) codes for all discharges.  The physician stated that all patients who were discharged from the hospital had at least moderate complexity on the day of discharge and so should be eligible for TCM.   (If you are still wondering about the requirements for reporting TCM, you can read the article I wrote about it, the comments and download Medicare’s FAQ  at  Wondering about TCM codes?

I don’t like to disagree with doctors, but I had to disagree in this case.  While it is true that most patients admitted to the hospital will still be moderately or highly complex on the date of discharge that is only one requirement for reporting TCM.  (If you read the article, you will remember that one key difference between the two TCM codes is complexity, moderate or high, selected by whether the patient has moderate or high complexity any time during the TCM period.  The TCM period starts the day of discharge and continues for 29 days. This is determined using the medical decision making criteria in the Documentation Guidelines).  The codes also require that the patient have medical or psychosocial problems that require extra work during a transition from inpatient, observation, partial hospitalization or nursing facility to home, domiciliary care, assisted living or rest home.  There must be a need for both a face-to-face service and non-face-to-face care coordination for the patient.

The CPT book lists the types of care that might be needed.  These include:

  • Communication with patient and/or caregivers
  • Communication with home health or other community services
  • Education to support self-management
  • Assessment and support for following the treatment regimen
  • Identifying resources the patient will need to maintain independence and follow the treatment plan
  • Facilitating access to care and services

This is in addition to reviewing the discharge summary and follow up diagnostic tests.  The physician or staff may also need to interact with other healthcare professionals, make referrals, educate the patient and/or family and assist in scheduling community and healthcare follow up.  It is insufficient review the discharge summary and see the patient in follow up and then to report TCM services unless additional non-face-to-face services are required.

Examples of cases that will not require TCM:

  • Patient admitted to observation for chest pain, ruled out, home without any community resources or additional referrals
  • Patient admitted with pneumonia, treated, discharged on oral meds.  Follow up with PCP arranged, but no other referrals, home care, community care or health care arranged.  No need for non-face-to-face education.  Patient able to return to independent living at home.
  • Patient with fracture, surgical treatment, discharged home.  Outpatient PT arranged at time of discharge.  No other follow up or referrals needed.

Transitional Care Management codes are not for every discharge.  They are for patients who have complex medical and psychosocial problems who need community resources, education and extra care to help in the transition from a facility to home.

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