# EMR procedure documentation



## Lisa Bledsoe

I have a situation with the EMR system my practice uses (purchased before my arrival) in which the providers think they can simply click on a procedure title and that's all they have to do...they don't document how they did the procedure, location, supplies, etc.   

1.  Does anyone else have this problem?

2.  For the life of me I cannot think of where to find where it states a description of the procedure *must be documented *(i.e. not just "trigger point injection").

HELP??


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## LLovett

Yes I just found out I am having this problem with a new provider. He is using Praxis. 

Ex: "Procedures Removal of skin tags, up to and including 15 lesions" 

I will be talking to him asap about this.

I found one thing on CMS that is specific to trigger point injections. 

http://www.cms.hhs.gov/manuals/downloads/com109c05.pdf

“Policy Number 14.20000 - Misuse of Column 2 Code with Column 1 Code - For example, CPT code 20550 (“Injection, tendon sheath, ligament, trigger point or ganglion cyst”) is intended to describe a therapeutic musculoskeletal injection. It would represent a misuse of the code to report this code with other procedures (e.g., CPT code 28292 for Keller, McBride, or Mayo type procedure) when the only service provided was injection of local anesthesia in order to accomplish the latter procedure.”

This is from the top of page 35. Obviously the only way to defend use of the code would be to have a description of what was done, not just the description of the code itself even though they don't actually say that.

Hope this is somewhat helpful,

Laura, CPC


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## RebeccaWoodward*

CPT Assistant states that the documentation for a trigger point injection should include the injections' location, number of injections, and muscles involved.


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## Lisa Bledsoe

Thanks Ladies.  I just wish I could find something in writing to support that a description of the procedure is *required*.  The EMR trainers have essentially told the providers that all they have to do is "click" on the procedure, but unfortunately clicking it doesn't describe it...


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## RebeccaWoodward*

Maybe they will believe if they are ever audited and required to refund money.  I have known insurance companies to review this particular procedure and reduce the procedure from 20553 to 20552 since the number/location of muscles was not documented.


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## LLovett

I have actually had a consultant tell me that in the EMR system when it assigns the ICD-9 code the doctor still has to dictate/free text the diagnosis in to get credit for it. 

I'm like, what???, the doctor picked that code why do they have to do it again? The rationale was that it could have been a clicking error or pulled forward from another visit and note even treated at this one.

This was supposedly from Palmetto, I have yet to see the documentation to support that and I thankfully no longer deal with Palmetto.

Laura, CPC


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## Lisa Bledsoe

We had our ICD-9 code selection ability blocked in our EMR because it did not give the prompts to choose a 4th and/or 5th digits.  The providers have to actually type the dx in the note for accuracy.  Thanks for all your input!!  I highly value all of you!!


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## LLovett

Heres a good one, very bottom of the page tells what the documentation has to have.

http://www.highmarkmedicareservices.com/policy/mac-ab/l27540-r2.html


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## Lisa Bledsoe

Thank you.
Maybe I need to clarify, this is not just for trigger point injections.  I was just using that as an example.  I'm referring to *any* procedure done in the office (lesion removals, biopsies, wart treatments, colposcopies, flex sigs, etc...)


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## donsqueen

Take a look at the medicare website. There are ramifications beyond just the risk of being audited for the provider. Without complete documentation, including the patient's reactions/lack of reactions to the procedure, how/what was done, the provider(s) are not fully documenting the treatment of the patient. One approach might be to ask the doctor what they would think if they received a copy of a note like that from another provider, but my guess is they would say "there were no complications". 

Medicare states in part "In order for a claim for Medicare benefits to be
valid, there must be sufficient documentation in the
provider's or hospital's records to verify the services
were performed, were “reasonable and necessary”, and
required the level of care that was delivered."

This is from https://www.noridianmedicare.com/p-...cd/docs/bulletins/issue_236_april_17_2007.pdf.


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## Lisa Bledsoe

Thanks Amy - but to take that further, what is considered "sufficient documentation"?  I always thought/was taught that a description of the procedure needed to be documented, not just that it was performed...


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