In the age of the electronic health records (EHR’s), patient encounter notes may become padded with extensive histories, medication lists, lab/diagnostic testing results that may not be obtained during, and which may not be pertinent to, the present visit.  Ironically, physicians may have an overabundance of patient information, but fail to document some of the work they actually did, which can adversely affect the level of service reported.

In the outpatient/clinic setting, physicians perform a great deal of behind the scenes work to diagnose and treat patients.   For instance, they review patient records, talk with other providers, order and review tests, and coordinate care.  Most of these activities cannot be counted if the provider is billing based on time because they occur before or after the patient’s visit.  Physicians must describe this work in their notes, so the effort is captured when the note is coded according to the elements of history, exam, and medical decision making (MDM).

As a coder, I have reviewed a significant amount of charts and have talked with many providers.  Continually certain items of MDM diagnosis, data elements, and risk go under documented or unlabeled, and are unused when choosing a level of service.  Often, physicians are not up‐coding as much as they are under documenting the services they perform.

To help prevent this, I ask physicians a series of questions when I meet with them:

Typically you have a number of patient complaints listed in your HPI, but not all of them are documented in your Assessment and Plan.  Did you address any of these issues during the visit?

If the physician did address the complaints during the visit, they must be listed to substantiate that the physician was dealing with more than one health issue.  This may increase the level MDM and possibly, the level of service.

Are you performing a record review?

Often, the record review summary is integrated within the HPI.  When many specific dates, lab findings, and other detailed information are given in the HPI, ask the physicians about the source of the data.  If the record review is not separated from the HPI and labeled, the information may be attributed to HPI only, and he or she may not get credit in the MDM section for this work.

Do you review the patient’s images or slides yourself?

If the physician performs this service and documents it, this may elevate the level of MDM.

Do you talk with the radiologist or pathologist?   

Talking with the testing physicians can contribute to a higher level of MDM, when performed or documented.

These are just a few examples of ways to ensure physicians are accurately documenting their work and are getting the proper amount of data needed to receive the appropriate level of E&M service.

In other words if the information provided by the patient and physician is documented properly within an EHR or a dictated patient medical record the correct level of E&M service should line up to the patient’s condition based on the number of diagnoses, data reviewed, and risk.