Welcome back, everyone, and my next talk is Top Documentation Errors in Gastroenterology, How to Avoid Cloning Issues, Inappropriate Template Use, and Contradictions. So we're going to talk a little bit about does your documentation support the level of service that you bill, and we've been talking about this all day. But we really want to hit it home to you that, you know, just to make sure you've got some good details in that assessment and plan to support that level that you're billing. Documentation tips, concurrent care issues, comments regarding cloning from your local Medicare contractors, and how to avoid template abuse, cloning, and dictation issues. All right, so again, decision-making or your level of visit is based on decision-making or total time. We talk about benchmarking. We talked about routine sampling of those high-level visits. You know, diagnosis coding, that is the biggest thing, that is the most important thing on your claim is the diagnosis code. So not where you had it done, when you had it done, what you had done, but why did you have it done. And so when we submit those levels of services, we are painting a picture. So if I bill a higher-level visit, I'm going to submit multiple diagnosis codes to support that level of visit. So if I have one minimal, one chronic condition, and I'm trying to bill a four, that could just be a red flag for the payer to go, oh, let's take a look to make sure. Okay. We talked about chief complaint, HPI, making sure we don't have contradictions between the two. And oftentimes, we see an issue when you've got a, let's say you have your staff, okay? Let's say your staff enters the chief complaint, they update the history, they do the review of systems, and then the physician comes along and does the HPI, the exam, and the assessment and plan. And that's how a lot of practices work nowadays is, you know, we have a triage nurse that goes in, takes the history, documents those pertinence, and then the provider will document the rest of that visit. And we see contradiction issues with this because either the patient didn't tell the assistant everything that was going on, or they forgot about something, and so the physician adds that into their HPI, and then again, it contradicts what was in that review system put in by the nurse. So you have to watch out for that, and you have to make sure that your note makes sense. We always say focus on impression and plan of care. Don't ever code from a problem list. Document your comorbidities and risk factors. If time supports your visit, document your time, and document those details to support it. More documentation tips, okay? Reason for visit, chief complaint reason for visit has got to be on every single note. Even your hospital follow-up visits need a chief complaint. This can be put into the subjective area of the visit, but make sure it's not too vague. So make sure your chief complaint doesn't say follow-up, or six-month follow-up, or hospital follow-up. Make sure you document why, what is the follow-up for, six-month follow-up for Crohn's. If you are still out there billing consults, which there are still some payers that accept consultations, make sure that you follow the consultation guidelines as far as documenting who sent you the patient and the reason they sent the patient to you. Don't use vague terms such as non-contributory or unknown. That is just kind of a vague statement. If it doesn't need to be there, just leave it off. Sometimes we see patients in the hospital where we cannot get a good history from that patient because they're intubated, sedated, whatever. So we always get the question, well, how do we document the history then? Well, luckily, it's not a requirement anymore. It won't be January 1st in the hospital. It's not a bean-counting requirement. We're just documenting history to support that chief complaint. But if you are unable to gather history, document why and document anything that you get from other sources. Review systems, again, you only need pertinent positives and negative review systems. When you're talking about records, make sure you say, make sure you document that you reviewed outside records, previous records. Make sure that you document every single lab that you order, review, et cetera. Avoid terms such as stable, improved, when billing higher levels of services. So sometimes I see like a provider bill level 5 consult for a GI bleeder, when you get down into the impression and plan, it says patient admitted with a GI bleed, stable, no transfusion required, we'll do an EGD tomorrow. That is not high level. If you say patient with an active GI bleed, acute blood loss anemia, their hemoglobin dropped, they're fatigued, they don't feel very good, we're going to get an emergent procedure, emergent EGD done on that patient, that's a high level. So make sure, I always tell providers, use your words, make sure, explain that scenario very clearly. Keep in mind, each note stands alone. Diagnosis should change from the initial visit through discharge. We see a huge issue on this, where you've got the consult or the initial visit with all the diagnosis codes you address. Well then, let's say you scope the patient, you find an ulcer, they get better, then the follow-up visit that you're billing should have the bleeding ulcer diagnosis code. Not all the stuff that was originally there, unless it's still active, of course. But as the patient gets through that hospital stay, diagnosis should become more specific and some diagnosis codes should be dropped when they're resolved. Each note stands alone. 99233, this is a hospital follow-up visit. This is pretty well equal to a five in the office by medical decision-making, okay? So right now, if you have a hospital visit with overall high medical decision-making, make sure you have a detailed history or exam to support that level. But again, that goes away January 1st. But again, making sure, 99233, and sometimes providers, if they don't understand or don't the guidelines, they often compare a level three follow-up in the hospital to a level three follow-up in the office, and that is not correct. It's equal to a five in the office. Concurrent care issues. This is something that, you know, we don't often discuss this because we don't see a ton of issues with this, but sometimes we get denials regarding, you'll get a denial back from a payer. Let's say you try to build a hospital follow-up. You get a denial back from the payer that says, oh, this was already paid to another provider. And you're sitting there going, you're looking through, you're looking at the claims, you're looking at the electronic record and your practice, and you're like, we did not build this. This is the only one we build. Well, it could be a concurrent care issue. And what concurrent care is, it's when services are performed by more than one provider on the same day to service for the same patient. Most commonly, it occurs when the same patient is seen by multiple providers of same or similar specialties for the same diagnosis. Reasonable and necessary service rendered with concurrent care may be covered if the medical record showed each practitioner supplied knowledge or services the attending physician could not provide. Only one E&M visit may be reported by the practitioner in the same specialty, same group on the same day to service. Otherwise, the physician and NPP must bill as though the services were provided by a single physician. If the claim is denied, it can be appealed by submitting signed documentation showing that we did a medically necessary visit. Recommend that you identify your practitioner's subspecialty to further demonstrate why it was medically necessary. So here's an example of what I'm talking about. Hospital follow-up visit for the same day to service where both the hospitalist and the gastroenterologist sees the patient. Both submit the claim with a primary diagnosis of melanoma, K92.1. All right, so GI should be the one submitting K92.1 primary. The hospitalist would focus on all those other conditions that they are managing while we come in and see that patient as a consultant. But again, if this happens, you get a denial like this, just submit your documentation to the payer. Don't just write it off. All right, cloning. Every Medicare contractor has a comment about cloning, okay? So we don't make this stuff up. So Noridian, if you're under Noridian, Noridian says there's a Q&A section on their E&M and their E&M. What does Noridian consider to be a cloned E&M note? If a note is very similar from day to day but is accurate to what's happened, is this still a cloned note? The answer, in general, if only data service and vital signs are different, then Noridian would most likely consider it cloned. We do realize that there may not be changes day to day detailing 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, okay? And so with these updated guidelines, though, with just only having to dock pertinent history and exam elements, we shouldn't be cloning our notes. We shouldn't even be doing it. NGS, this is another Medicare contractor. Documentation which is cloned is considered cloned when it is worded exactly like or similar to previous entries. It can also occur when documentation is exactly the same from patient to patient. Individualized patient notes for each patient encounter are required, okay, whether the documentation was the result of an electronic record, a preprinted template, handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverages of services due to the lack of specific individual information for each unique patient, right? So identification of this type of documentation will lead to denial of service for lack of medical necessity and recoupments of all overpayments made. CGS pretty well says the same exact thing, okay? I'm not going to read it to you. It's the same exact thing. Palmetto, okay, so they're referring to it as it's cloned, it's cut and pasted, carried forward, and it doesn't matter what format your documentation is in, okay? It can't be cloned. Over-documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for higher, building higher levels of services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox. We all are very familiar with the click of the checkbox, okay? You click it and everything pre-populates. So such features produce information suggesting the practitioner performed a more comprehensive were actually rendered, okay? Just make sure, just make sure that you are taking out that's, you know, taking out the pertinent information that you, things that you didn't do. Uncheck the things that you didn't do or the things that you didn't ask. WPS also references cloning, and they basically said, you know, each note stands alone, but we have to make sure that we are not cloning as well. So polling question. Auditors are trained on the quality of the medical record. Which of the following scenarios best represent a customized and medically necessary service? The first one, chief complaint, interval history, copied exam, and copied plan of care. Or a copied chief complaint, updated interval history, updated exam, and updated plan of care. Chief complaint, copied interval history, copied exam, updated plan of care. Or a copied chief complaint, interval history, updated physical exam, and copied plan of care. Good job. 78% of you said a copied chief complaint, updated interval history, updated exam, updated plan of care. Everything should be updated. Chief complaint, that doesn't necessarily change from day to day. All right. Safe use of templates. So medical necessity should be your driving factor. Every note should not look identical, okay? And it has to be specific to the chief complaint. And again, I already talked about this. Medical staff entering any portion of that patient encounter, the provider, who is responsible for the documentation? The provider is. So if you're signing off on a note that is contradictory, the chief complaint is not even accurate. I've seen that before, too, where we've left the chief complaint from a year ago on this note, and the patient's here for something completely different, but it wasn't updated. You're at the end of the day, before you sign that note, take a review, take a quick look, make sure it makes sense. The note should flow. Your chief complaint should flow to the HPI, and your HPI should flow to the assessment and plan of care. Telehealth. Review your telehealth physical exam templates. When COVID first hit and all of us were almost seeing patients 100% virtually, we had big issues with templates. So the provider would document that this was an audio-only encounter, but there was a physical exam on the note. Or they documented that it was an AV visit, but there were physical exam elements that could not be possible without touching, without putting your hands on the patient. So guys, review those templates and make sure that they make sense. I always say I like the basic soap note. Back in the day when our providers were handwriting notes, I would much rather look at, they would write them in a soap note format, and I would much rather look at a soap note, a one-page soap note, than an eight-page dissertation of regurgitated information that makes no sense to why you're seeing the patient today. I've got to spend 15 minutes trying to figure out what changed, okay? We shouldn't be doing that. Keep to a basic, pertinent note. This continues to be a significant problem that creates unnecessary redundancy and at times inaccurate information. I have literally seen a follow-up hospital visits I think are the worst. When you're seeing a patient multiple days in a row, there's a kind of that, oh, I'll just pull this information over, update a couple little things, and sign off on it. Just make sure that you're updating enough information to what was accurate. I've seen progress notes that say subjective, patient is alert and oriented, and then objective, intubated sedated on vent. How is that possible? Okay, well, it's because they copied over the exam. They didn't update it, so you've got to make sense. Doctors, again, are trained on the quality and not the quantity of your medical record, and they're actually looking at multiple records in a row. They can request six follow-ups for Sally, for the patient Sally, and they can put six records side-by-side, and if they're all cloned, they'll pay for one, but they'll deny all the rest of them, or they'll ask for their money back. Voice recognition systems are a problem as well, okay? I always say, dragon, train your dragon, be sure your documentation makes sense. If there are blanks that are returned on your dictation notes, or blanks because dragon didn't hear you, you've got to complete the information. Don't just sign the note and keep the record in the patient's chart with blanks all over it, okay? That doesn't look very good, and remember that what you sign is a medical legal document, and your name is on the claim. This one is one of my little funnies at the end of the day. It says, I don't know what's worse, trying to read a doctor's handwriting and charts, or their typing errors in the EMR. All right, thank you.

gastroenterology

documentation errors

diagnosis coding

accurate documentation

voice recognition systems