# EHRs and documentation



## jbrashear (Apr 28, 2011)

Hello Everyone,

My providers use an EHR in their practice and they often do the following:

Instead of writing a sentence stating, "strep screen done today" or something similar, they add the diagnosis code to the note, list updated meds for that problem, then place "orders". Then they click the procedure code for that order. It usually looks something like this:

Problem #1: Pharyngitis, Streptococcal (ICD-034.0)
Updated medication list for this problem includes:
    Motrin 800 mg tablets... one po tid prn pain

Orders:
Strep Screen (87880)
Bicillin CR 100,000 (J0561)
99213 Est Level III (99213)

This is all I get in the way of documentation for the order of a lab test. Would the above method of documentation for an ordered lab pass an audit? 

Thank you,

Janice Brashear, CPC


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## cheermom68 (Apr 28, 2011)

*order*

As an auditor, I would not accept it as documentation to support that the test was performed in the office.  It shows that the test was ordered but not that it was performed.
LeeAnn


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## jbrashear (Apr 28, 2011)

cheermom68 said:


> As an auditor, I would not accept it as documentation to support that the test was performed in the office.  It shows that the test was ordered but not that it was performed.
> LeeAnn



Thank you! Those are my thoughts exactly. I just wanted to get some feedback in order to relay that confidently.


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## m.j.kummer (Apr 28, 2011)

Because of the documentation guidelines statement:  “If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.”  I have a few questions:
1.  Are you coding/billing for the ancillary service or is it just part of the medical decision making process?
2.  Is there an examination of the throat with findings consistent with Pharyngitis?  What indications are there for performing a strep test?
3.  It would be better for the findings to indication the diagnosis of Pharyngitis, Streptococcal (ICD-034.0) verified per culture (or other appropriate)
4.  Shouldn't the updated medication list for this problem include?
     a.  Bicillin CR 100,000 as well as how it is administered
     b.  Motrin 800 mg tablets... one po tid prn pain

There are too many unanswered questions.


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## jbrashear (May 15, 2011)

m.j.kummer said:


> Because of the documentation guidelines statement:  “If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.”  I have a few questions:
> 1.  Are you coding/billing for the ancillary service or is it just part of the medical decision making process?
> 2.  Is there an examination of the throat with findings consistent with Pharyngitis?  What indications are there for performing a strep test?
> 3.  It would be better for the findings to indication the diagnosis of Pharyngitis, Streptococcal (ICD-034.0) verified per culture (or other appropriate)
> ...



I will try to answer your questions in order:
1. I am coding and billing for the ancillary service.
2. Patient comes in w/complaint of sore throat, under exam section, the provider may note whether the throat is injected, red, etc. 
3. The providers always code 034.0 if the patient has a positive rapid strep test, but they do not always document the test performance or its result. You have to have that in order to code strep pharyngitis. BTW, they do most of their own coding. I just verify and bill. (hate that because I could code their work so much better myself).
4. You are correct, but again, the providers don't always do what they are supposed to in documentation. (Rarely EVER!) And there is nothing I can do about it because I have not been given that authority by my "supervisor".

Hope I answered your questions well enough. I could gripe all day about my job, but griping does nothing. I need to move on to a company, possibly my own, that values quality and integrity in healthcare. 'Nuff said.


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