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

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

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The Top Documentation Errors in GI were discussed in a presentation by Kristin Vaughn, a healthcare consultant and lead auditor for AskMueller Consulting, LLC. The errors discussed included cloning issues, inappropriate template use, and contradictions in documentation. It was emphasized that documentation should support the level of service billed.<br /><br />For medical necessity in E&M coding, benchmarking reports should be run monthly to compare providers' levels of service and diagnoses to national statistics. Payers routinely sample high-level visits, so it is important to review all high-level visits before claim submission and educate providers on any errors.<br /><br />Diagnosis codes can trigger down-coding if not properly submitted. Therefore, providers should ensure that the chief complaint, HPI, and impression and plan of care do not contradict each other. The assessment and plan of care should accurately reflect medical necessity.<br /><br />Providers were advised to focus on an impression/plan that includes each problem addressed with a corresponding plan. If decision making doesn't support the level of service, time can be used to support billing.<br /><br />Documentation tips included the need for a chief complaint for every visit, documenting the name of the requesting provider for consultations, avoiding terms like "non-contributory" or "unknown" for family history, and documenting attempts to gather a history from other sources when unable to obtain it directly.<br /><br />Concurrent care issues were discussed, with the recommendation to bill as if the services were provided by a single practitioner unless they are for unrelated problems. Denials for concurrent care services can be appealed by providing signed documentation showing medical necessity.<br /><br />The presentation also highlighted the dangers of cloning in documentation. Medicare contractors such as Noridian, NGS, CGS, Palmetto, and WPS consider cloned documentation to be a misrepresentation of medical necessity and may deny services. Over-documentation and the use of templates were also cautioned against.<br /><br />The importance of unique, specific documentation for each patient encounter was emphasized. Practices were advised to develop policies to address inappropriate cloning and avoid the copy/paste option. The use of voice recognition systems and dictation was discussed, with a reminder to ensure that documentation is complete and makes sense.<br /><br />Overall, the presentation provided valuable insights and tips on how to avoid common documentation errors in GI healthcare.

Keywords

documentation errors

cloning issues

inappropriate template use

contradictions in documentation

medical necessity

E&M coding

diagnosis codes

concurrent care

denials

GI healthcare