2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing | November 2021-13 - Top Documentation Errors in GI

13 - Top Documentation Errors in GI - Cloning and Template Issues_Vaughn

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In this presentation, Kristin Vaughn discusses the top documentation errors in the gastrointestinal (GI) field and provides tips on how to avoid them. The three main errors she focuses on are cloning issues, inappropriate template use, and contradictions in documentation.<br /><br />Cloning refers to the practice of copying and pasting information from previous notes into current ones. Medicare contractors consider cloned documentation to be a misrepresentation of medical necessity and may deny services based on this. To avoid cloning, providers should ensure that each patient encounter is unique and that the documentation is specific to the patient's current condition.<br /><br />Inappropriate template use is another common error. Providers should be cautious when using pre-printed templates or electronic health record systems, as the information in these templates may not accurately reflect the patient's current condition. It is important to review and edit the information before finalizing the note.<br /><br />Contradictions in documentation can also cause issues. Providers should ensure that the chief complaint, history of present illness, and assessment and plan of care align with each other. Inaccurate or contradictory information can result in down-coded claims or audits.<br /><br />Vaughn also emphasizes the importance of medical necessity in determining the level of service billed. Providers should regularly run benchmarking reports to compare their coding practices with national statistics for their specialty. Monitoring high-level visits and educating providers on proper coding can help avoid errors.<br /><br />Overall, providers should strive for accurate, specific, and individualized documentation for each patient encounter. By avoiding cloning, inappropriate template use, and contradictions, providers can ensure their documentation supports the level of service billed and reduce the risk of audits or denials.

Keywords

documentation errors

gastrointestinal field

cloning issues

inappropriate template use

contradictions in documentation

medical necessity

unique patient encounter

pre-printed templates

electronic health record systems

accurate documentation