Many physicians and administrators were relieved when ICD 10 was once again delayed until October 1, 2015. The additional time allows for the update of practice management systems, electronic medical record implementation or software enhancement and testing of successful claims with carriers. It also allows physicians to improve on the root of correct coding—the documentation.

As a Certified Professional Coder, I have seen the request for internal audits increase over the last few months; this is a good way to evaluate coding patterns, documentation support and medical necessity. Medical necessity is the overarching criteria for payment of a provided service, not the amount of documentation. The nature of the presenting problem should support the level of the service provided, according to the 1995 and 1997 documentation guidelines.

Physicians have spent so much time implementing electronic medical records and demonstrating meaningful use, the overall focus on good documentation has suffered. Each visit’s documentation should stand alone; it should be a chapter in a story that reflects on the past, present and plan for the patient’s current state of health. The history is very important because it sets the tone for the exam and medical decision making. The history of present illness should contain descriptive elements about what is happening today with the patient. A chief complaint should always be documented; it is the patient’s reason of why they are present for service, follow-up is not a chief complaint. Exam guidelines are very important, there are benefits to 1995 and 1997 guidelines but 1995 guidelines are more vague than 1997. The plan for the patient should be a conclusion, a thought process that supports the orders and the management of the illness, or episode of care.

Electronic medical records often contain a calculator that arrives at a coding level by the activity within the note, but these calculators are not always accurate which is another good reason for an internal audit. I recommend an audit to our clients within 6-8 months after implementing an HER, because of the way the provider’s document has been greatly altered. The new claim forms allow up to twelve diagnoses opposed to only four in the past, carriers are building risk levels for all patients. Physicians worry they may be held responsible for the diagnosis if they list it, but that is not the case. It is important to list any diagnosis that will alter the medical decision making for a patient. Another issue stemming from EHR notes is the copy and paste function or pulling past information forward. The OIG is really focusing on this issue from an overpayment standpoint but it is also a patient safety issue. Orders can be confusing to staff when notes list past documentation.

One important issue I see when reviewing evaluation and management notes is a lack of understanding of the new and established visit guidelines. The face to face time is listed for every level of care. The history is extremely important in new patient visits and it is often the reason a visit is over-coded. Physicians and administrators can use the baseline internal audit to correct problems and assess specificity in the notes as we move toward ICD 10. Once a practice adopts a compliance plan, the internal audit is part of the ongoing compliance. Don’t hesitate to contact me if you would like to assess your documentation while there is plenty of time to get on board with education and improvement.