This talk, I'm going to talk a little bit about cloning, template use, contradictions, good stuff like that. So something, does your documentation support the level of service build? And I know we've talked about this in many aspects today, but just a few more tips to add to that. Concurrent care issues, going to talk a little bit about concurrent care issues, what it is and how to avoid some of those claim denials. Medicare contractors' comments regarding cloning issues. So it's just not the bad, mad auditor saying that you can't copy and paste. Actually, the Medicare contractors say you can't copy and paste too. And then talking about how to avoid template abuse, cloning, and talk about some dictation issues. All right. So question. A coder in the office reviewing a physician's clinic note notices the chief complaint contradicts the HPI. What is the best way to address the issue? Ignore it. Nobody will read it anyway. Talk to the staff member who entered the chief complaint. Have the physician add a late entry or correction to the note. Or sign into the EMR and correct the note yourself. So 88% of you said have the physician add a late entry or correction to the note. And that is correct. You do want to talk to the staff member too that entered the chief complaint. But ultimately, the provider should make corrections to that note by entering an addendum, late entry, et cetera. All right. So a little bit more about E&M and medical necessity. So remember, do your benchmarking. Make sure that you're assigning the correct and accurate diagnosis to the highest degree of specificity. Make sure your visit is based on decision making or total time. Sample those higher level visits before they go out the door, especially if you've got new providers. As I always say, review their notes. Give them some education, especially if they're fresh out of school. I like to kind of say they're kind of the guinea pigs. We can mold them. We can make sure that they have good habits and not bad habits going forward. So that's a place you can start. Diagnosis codes can trigger a payer down code for the level of service. So think about that. Remember, I said before that your diagnosis code is pretty well the most important thing on that claim. And so if the payer comes, if the payer gets a high level visit from you, but the diagnosis code really doesn't support that higher level of visit, that can actually trigger a review too. So an example. Established patient with a diagnosis of GERD submits a level four follow-up, but nothing else was addressed or nothing else was linked on the claim. So it could have supported a four had there been maybe endoscopic workup, risk factors documented, time documented, things like that. So just make sure that all those diagnosis codes get pulled in on that claim as appropriate. If you receive multiple down coded claims, this can trigger an audit. If one provider, and I talked a little bit about this whenever I was talking about benchmarking, if one provider in the group is an outlier, this can also lead to an audit for the entire practice. Pay close attention to the core elements. We've talked about this. I've talked about this. Kathy's talked about this. Chief complaint, HPI, and the impression and plan should not contradict one another. We see this a lot. And again, I think it has to deal with we have a lot more staff entering the information into our notes. And that's good. But they have to be educated on how important it is to get all those elements accurate. But it's also important for the provider to review those elements to make sure that they're correct and that they match the impression and plan. The assessment and plan is where medical necessity is kept. Make sure all conditions are addressed are brought into the assessment and plan of care. And again, remember, I said there's many times where you've addressed something in the HPI and you didn't bring it down into your impression and plan. And that's really where the brain, the medical necessity of that note is. Compare the diagnosis codes that were submitted against your visit as well to make sure. This goes for hospital too. And I think the biggest disconnect that I see as far as diagnosis codes not matching what's in the note is hospital. And a lot of times it has to deal with the flow, the workflow. So, you know, you might still be working on a charge sheet. So you might say, okay, patient A, I did a consult on him on Monday and then I saw him in follow-up on Wednesday and Friday. But all of those visits are on the same charge ticket and the diagnosis codes remain the same for every single one of those visits. But if I pull the note up, yes, those diagnosis codes were accurate for the initial consult, but then they should, things should be removed if they've been resolved. Or if I have a more definitive diagnosis. So they might have came in for a GI bleed, but now I know they have a bleeding ulcer. So then that diagnosis code should change as well. So each note stands alone. It's pretty well what you have to remember. Each note stands alone. Oftentimes you don't fully document everything you did. And remember, Kathy said, if it's not documented, we don't know that it's done. Focus on your impression and plan. Make sure your diagnosis codes match. I always say too, if you've listed four diagnosis in your assessment, you should have a plan to match those diagnosis codes or just something that you've addressed, a comment. Document your comorbidities, document your risk factors. And keep in mind, I know Kathy went over this, if decision-making doesn't support your level, use time to support your billing. And Dr. Littenberg had a good point on time, and he's got like a template. So like if he knows he's going to bill by time, he could click on that box, and it'll prompt him to put the appropriate information in there. All of your EMRs should be able to do that. You should customize it. Make it easy. Because a lot of times when I talk to providers and educate them about, they're like, no, I don't bill by time because I have to, you know, type in all this stuff, and it makes the note, you know, weird, and this, that, and the other. Make a template. Build a template. If you're not sure how to do that, talk to your IT department. They can incorporate a template like that for you. That way if you know, okay, I'm going to time this visit, you click the box for time, and it prompts you to put in that information that you need. Okay. A chief complaint reason for visit must be documented for every visit. This isn't just office. This is hospital notes. This is rounding notes, progress notes. Every visit should have a chief complaint. It establishes medical necessity for why you're seeing the patient today. If you're still billing those consultations, so whether it's outpatient consult or inpatient consult, be sure the documentation requirements are met. Be sure you document the name of the requesting provider and the reason. When we're dealing with gathering history from the patient, family history non-contributory, family history unknown, family history negative, none of those are acceptable. Okay. Make sure it relates back to the chief complaint. If the patient doesn't know their family history, document why they don't know their family history. They're adopted, or they just don't have any family around to know. Okay. That has to be, there's another one. I did a review not too long ago, and it was a default template in the hospital that it automatically, if you didn't enter your family, like if you didn't type in the family history, it would automatically default to family history not on file. So make sure that your electronic record, you should create hard stops for that information. That way you have to put information in there before you go on or before you sign your note. We get this issue a lot is what happens if I cannot get a history from the patient? So remember, when you're in the hospital and you're relying on the documentation requirements for the hospital, those are the old 95, 97 guidelines where we're bean counting the history and exam elements still. Well, we always get that question. Well, what happens if I can't get a history from the patient? How do I document that, right? So you should document any attempts, whether it's, you know, from the chart, from nursing staff, anybody of family members. Then once you document that, you can document like review of systems unable to be obtained and document the reason why. Don't just say history unobtainable. Okay. You have to document why. When we talk about review of systems, again, hospital documentation, when you have to have all of those elements. Best practice recommendation I can give you for review of systems in the hospital. And again, these are initial visits. You don't have to have a complete review of systems for follow-up visits in the hospital. Document your pertinent positives and negatives. Then you can make a statement that says all remaining review of systems were reviewed and negative except those mentioned in the HPI. All right. So think about that. You don't have to have a full 10 individual. You can document your pertinent and make that statement. Now, when you're making that statement, though, don't, and I've seen this template, you know, it's one of those templates like it goes away because I tell them that it doesn't work. And then the next time I do a review on it, it's back again. It's like the never-ending template that won't go away. So avoid statements such as a 10-point review of systems were reviewed and negative. Why? Well, there's 14 total. An auditor can say, which 10 did you review? So just say all or 14. Don't say 10. Don't say 12. Providers should document any previous records that reviewed summarized. And again, I've talked about this, talked about this in my first two sessions. Kathy talked about using your words stable, improved. If everything is stable and improved and you're trying to build a high-level visit, you might not want to do that. You have to, you know, they might be stable, but are they responding adequately to the therapy that you're doing? Is there another underlying issue that you've addressed? And again, keep in mind each note stands alone. Talk a little bit about concurrent care issues, all right? So what that means is when services are performed by more than one provider on the same data service on the same patient. And I'm not talking about two visits in your office or two visits from your group being billed out the same day. You can't do that. I'm talking about a hospitalist bills a progress note and you bill a progress note and one of you gets denied. And what it is is if the patient is seen by multiple providers on the same day, but both of you report the same diagnosis code as primary, you may get a denial for medical necessity, all right? So what do you do? Well, you just submit your documentation. So if you get a denial like that, submit your documentation to prove, no, we saw the patient, yes, it was medically necessary, okay? So appeal it. We recommend that you identify practitioner subspecialty to further demonstrate why it was medically necessary, okay? So yes, you might be board certified in internal medicine, but your GI, you should be the one submitting the GI specific diagnosis code as primary. So that's a concurrent care issue. So here's an example. Hospital follow-up visit for the same data service where both the hospitalist and GI sees the patient. You both submit the claim with a primary diagnosis of melanoma. GI should bill melanoma as primary, but the thing is you can't control what the hospital is billing primary. But they really should focus on all those other diagnosis codes that they're following. So what happens is we might get a denial that says, oh, this is a duplicate service, or claim or service was already paid to another provider. Again, if you get that and you're like, no, I didn't bill anything else for any of my doctors, it's probably another service. So just submit your note and you should receive payment upon review. Let's talk about some cloning, copying, template issues, et cetera. So these are some comments that your Medicare contractors have when they address the cloning and copying issues. And this was, I think the biggest issue we see is at the hospital as far as copying and pasting. We understand that hospital electronic records have give you the ability to literally copy one note day after day after day after day. And I mean, I could probably write a book on the cloning that I've seen where the notes don't make sense because you've copied it every single day. You know, I've looked at three, four, five, six notes in a row, and every note says patient had an acute episode of chest pain this morning, stat EKG ordered every single day. That's an issue. You've got to make sure and change the note to make sense and to be current. So Noridian, this is a Medicare contractor, and the question says, what does Noridian consider to be cloned on a visit? If a note is very similar from day to day, but is accurate to what happened, is this a cloned note? They answer, in general, if only the data service and vitals are different, then Noridian would most likely consider it cloned. We do realize that there may not be changes day to day to detail the stability of the patient, but it is important to include the details in the documentation. Medical necessity is also important here. To repeat a family and social history on every visit every week or two would be considered cloning, or at least not reasonable and necessary. So it's interesting that they comment on that family history and the social history, and I think that, you know, when they came out with the E&M guidelines is you only, in the office, you only have to document the pertinence, and you don't have to regurgitate the patient's past medical family social history every time they come into clinic unless it's changed. You don't have to keep putting that information into every single one of your notes. It's not necessary. NGS addresses the same thing. It says documentation is considered cloning, is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when the documentation is exactly the same from patient to patient. Individualized patient notes from each encounter are required, all right? Whether the documentation was the result of an EMR, use of a preprinted template or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity for coverage of services, okay? And they will recoup your money if they've noticed cloning, right? CGS also addresses this, and I'm not going to read every single one of these, but I encourage you to go to the slide of your Medicare contractor and read what they say. They all have a little bit of a different answer or opinion on it, but they pretty well all go with the fact that, hey, if all your notes look the same, we're going to recoup payment. So Palmetto actually addresses it, too. And again, you just find your Medicare contractor, and you can read it. So safe use of templates. Medical necessity should be your driving factor for templates. Every note should not look identical and must be specific to the patient's chief complaint. If medical staff, and I know I've made a comment on this today, is entering any portion of that information, make sure it is reviewed before you sign that note. You are responsible for the note. And then making sure that chief complaint flows with the HPI, which flows with the assessment and plan. And providers should also carefully review telehealth physical exams. And I know we had already addressed this because we got that question during the first Q&A session. It was a very good question, is, you know, how do we really document a physical exam? So an audio video exam should only include general statements that can be commented on just by seeing the patient and not touching the patient. Again, unless you ask the patient to do that, but you probably should make a note that asks the patient to palpate abdomen, doesn't feel tender in the right upper quadrant, whatever. Okay, it's got to make sense. Address cloned documentation with your providers. I like the old SOAP note that we used to use, and that was kind of pre-EMR. Subjective objective assessment and plan. You can make a progress note short and sweet, and it still support the level you're trying to build. Don't make it too hard. Again, cloned documentation continues to be a significant problem that creates unnecessary redundancy and at times inaccurate information. And like I said, I have read multiple notes where they don't make sense because they were not updated. So develop, this is, again, back to compliance, right? If you are seeing this done internally by one of your providers, you need to address it. If you don't feel comfortable addressing, you go to your supervisor to address it, or you go to the director or the president and address it. It's very serious. Auditors are trained on the quality, not the quantity, and they are requesting consecutive visits. So they don't want to just look at one progress note for Ms. Smith. They want to look at three progress notes that you build for Ms. Smith, and they're going to look at customization. Also, reminder on dictation and voice recognition. So I always say, because I know there is a voice recognition program, Dragon, and I always say train your dragon. You get those systems, they've got to get used to your voice, the terms that you use. So when you're new to that voice program, read through your notes. I can tell, and most of the time I see it in the clinic setting, but I can tell when a note's been dictated by voice recognition because there'll be some weird paragraph that it picked up from someone else having a conversation or whatever. I've just seen really, really bad documentation by those voice recognition systems. So be sure, review your note before you sign it. Another thing is if you're using the old school dictation and you get a note back. So let's say you dictate an ERCP report in the hospital, and you get that note back and there's blanks everywhere. Ninety-nine percent of the time I see the blanks not filled in and it's signed off. Fill those blanks in. That means the transcription didn't know what you said, it didn't come through right, et cetera. You have to fill those out or fill those in. And remember, what you sign is a medical legal document and your name is on the claim you're responsible. Thank you for listening. Just a little humor here. I don't know what's worse, trying to read a doctor's handwriting in charts or their typing errors in the EMR. And that is very true. I used to pout when I'd have to go to medical records and audit charts in the medical records department, and I could not read the handwriting to save my life. I finally got used to it. But now that we're in the EMR world, it's a little different. So it's challenging.

medical documentation

billing

cloning

template use

claim denials

accurate documentation