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

Pdf Summary

This document discusses the top documentation errors in gastroenterology and provides tips on how to avoid them. The presenter emphasizes the importance of ensuring that documentation supports the level of service billed. Benchmarking reports should be run regularly to compare provider levels to national statistics. Payers frequently sample certain high level visits, so it is recommended to review and educate providers on any errors before submitting claims. <br /><br />Medical necessity for evaluation and management (E&M) visits should be based on decision making or total time spent. Diagnosis codes can trigger down-coding of the level of service. It is essential to ensure that the chief complaint, history of present illness (HPI), and plan of care do not contradict each other. The assessment and plan of care is where medical necessity is kept, so all conditions addressed should be included. The provider should document everything done in the encounter and focus on an impression/plan that includes each problem addressed. Time can be used to support billing if decision making doesn't support the level.<br /><br />Documentation tips include documenting a chief complaint for every visit, documenting the name of the requesting provider and reason for consultations, avoiding terms like "non-contributory" or "unknown" for family history, and documenting attempts to gather a history when unable to do so directly. Providers should document pertinent positive/negative review of systems and only document relevant review of systems related to the chief complaint. <br /><br />Concurrent care issues arise when more than one physician treats the same patient on the same date. Only one E/M encounter can be reported by practitioners in the same specialty, unless services are for unrelated problems. Denials for concurrent care can be appealed by providing signed documentation showing medical necessity. <br /><br />Template use and cloning issues are discussed, with Medicare contractors providing comments on what they consider to be cloned notes. Cloning occurs when documentation is exactly the same from patient to patient or when only the date of service and vital signs differ. Cloned documentation does not meet medical necessity requirements. <br /><br />The use of voice recognition systems and dictation is mentioned, with a reminder to ensure that documentation makes sense and to complete any missing information before finalizing.

Asset Subtitle

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

Keywords

documentation errors

gastroenterology

benchmarking reports

medical necessity

E&M visits

chief complaint

concurrent care

cloning issues

denial appeals

voice recognition systems