2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-Top Documentation Errors in GI

Pdf Summary

In this presentation, healthcare consultant Kristin Vaughn discusses the top documentation errors in gastroenterology and provides tips on how to avoid these errors. She emphasizes the importance of ensuring that documentation supports the level of service billed. Vaughn suggests running benchmarking reports monthly and yearly to compare provider statistics to national averages and identify any outliers. Providers should review high-level visits prior to claim submission and educate providers on any errors discovered.<br /><br />She also highlights the importance of accurately linking diagnosis codes to the level of service billed. Failure to do so can result in down-coding or trigger an audit. Providers should ensure that the chief complaint, history of present illness, and plan of care do not contradict each other. The assessment and plan of care should include all conditions addressed, and the diagnosis codes submitted should align with the chief complaint and plan of care.<br /><br />Vaughn provides several documentation tips, such as documenting a chief complaint for every visit, avoiding terms like "non-contributory" or "unknown" in family history, and documenting attempts made to gather a patient's history when unable to do so directly. She recommends including pertinent positive/negative review of systems and only documenting review of systems related to the chief complaint for office visits.<br /><br />Vaughn also addresses concurrent care issues, where multiple providers of the same or similar specialties see the same patient for the same diagnosis. She explains that only one E/M encounter can be reported by practitioners in the same specialty on the same day unless the services are for unrelated problems.<br /><br />Furthermore, Vaughn discusses the issue of cloning in documentation, where notes are very similar or identical from day to day. She highlights that cloning is not considered reasonable and necessary and can lead to denial of services. She also advises against the inappropriate use of copy/paste option in electronic health records, as it creates redundant and inaccurate information in the medical record.<br /><br />Finally, Vaughn provides tips for using voice recognition systems and dictation. She advises training the system to ensure accurate documentation and completing any missing information before finalizing. She reminds providers that they are legally responsible for the information they sign on the claim.<br /><br />Overall, the presentation provides valuable insights into the most common documentation errors in gastroenterology and offers guidance on how to avoid them.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

healthcare consultant

documentation errors

gastroenterology

avoiding errors

benchmarking reports

linking diagnosis codes

down-coding

chief complaint

review of systems

concurrent care issues