Documentation Tips

Documentation Tips: Supporting the Thought Process

Documentation Tips: Supporting the Thought Process

For E/M services, you are paid principally for your thought process. For good reason, Medicare calls E/M work “cognitive services” to distinguish it from “procedural services”. They recognize that thought process and the complexities of establishing a diagnosis have long been undervalued in the payment system.

Most of the coding industry distinguishes a 99283 from a 99284 principally from the number and types of tests and interventions ordered. EGO believes that a clinical approach to coding allows more than tests or interventions to identify the higher risks in certain presenting problems and when lower acuity conclusions are reached we will report 99284 services if the potential for higher risk conditions are made clear by the documenting physician.

Hitting the history and exam bullet points was never a very good way of quantifying the value of an E/M service. The new payment paradigm is likely to require more documentation of the value of decisions and how you reached them. “Thinking in ink”, including documenting differential diagnoses on lower level acuity cases, increases the value of your record to other care givers and provides proof of work associated with the higher levels of care.

Note all clinical interventions that were ordered such as O2, inhalation tx, IM meds, IV meds with the rate of infusion, etc.. Do not rely on nursing notes to identify these ask they often do not make it into the audited chart. Unsympathetic payer reviewers are not required to look for them.

Always note all labs that were ordered and provide specific comments on lab results such as “probably sub-clinical due to…”, “no metabolic acidosis”, “slightly elevated due to…” Defend your logic with risk analysis comments. The value of your work is in eliminating high risk conditions not just finding and treating them.

Always explain WHY you did NOT do what you did not do. Note why you decided NOT to do a medical intervention or an advanced study like CT or ultrasound or admission using terms that support your ability to preclude the need for expensive testing.

State whenever nursing notes or old patient records were reviewed not just requested (extra credit for reviewing them). A comment regarding some pertinent information obtained from the records, or from any source other than the patient, should be recorded (EMTs paramedics, police, etc.)

Document all discussions with private attendings and consulting physicians as to what was discussed, not just who you spoke with. Note whenever a private attending requests a consult from the emergency physician. Document the discussion with the private attending that followed the consultation with the patient.

Document clear discharge plans including referrals for follow-up. Note on patient instructions exactly what the patient must do and when.

Always note each diagnostic interpretive service performed by the ED physician. Comments like, “read by me”, “read by EP”, “read by radiology” leave no doubt as to the interpreter

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