# Examination Documentation



## maine4me (Apr 25, 2012)

Currently, I am working with one of our general surgeons who is embarking on the adventure of documenting office services in the EMR.  He has been using the EMR for a couple of months, so I am reviewing his notes to ensure that he is capturing all the necessary components.

After looking at his notes, I feel it necessary to streamline his process.  Believe it or not!  Let me put it this way a follow-up visit may have a note approximately 5 pages long.

Since this is general surgery there is usually a specific problem being treated.  My concern is that he does a complete examination for every patient, new or established.  Is there any reason that this may be a red flag to an outside auditor?

I do not want to change his clinical process, but to me it almost appears that he is trying to bump up the charge with his exam.  I just would appreciate any thoughts, and advice as to how to approach this if this could be a trouble spot for him and the practice.

Thanks


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## martinni1974 (Apr 26, 2012)

What you are likely seeing is partialy "cloned" documentation from the patients prior visits or your physician's "favorites" that he moves into the patient's note for the day.  Regardless of how many words are on the PG note the level of service must align with the nature of the presenting illness/CC/reason they are there.  

*Scenario:*
patient comes in for 4 month follow up.  Everything is great no issues, no active issues to manage and he says see you in a year or maybe no additional follow up required.  If your billing a 99214 or 99215 because the EHR cloned comprehensive or detailed documentation from prior visits it will most definately raise a red flag, especially with your bigger ins carriers and Medicare.

I am an auditor and we do look for cloned, copy and paste, favorites, and other types of EHR generated documentation.  Remember, the elements of the E&M must be medically necessary and tie back to the nature of the presenting illness/CC/reason they are there.  

EHR's cannot replace a human coder/auditor as the logic they are programmed with can not encompass all of the nuances associated with selecting the proper level of E&M especially on established E&M codes where two out of three key components is required.

Hope this is helpful!


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## maine4me (Apr 26, 2012)

Thanks Nicole!  This does help.  Now I have to determine how to present this to the doctor.


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## martinni1974 (Apr 26, 2012)

Here's some tips to prepare for your discussion:

First does your Practice Management system/billing system interface with your EMR? Some practices still have this separate.  

Run a report such as a procedure productivity report and filter by physician, pt name or actt#, DOS,  and CPT code.  Run just CPT code 99214 for example, to start.

Compare documentation between a couple patients to see if any is identical in any areas such as hist (ROS is a big area of "cloned" documentation) also review the PE with the ROS/HPI.  many times the ROS/HPI will say, for example; "patient has abdominal pain and the PE will show no GI exam.  Things like this should make you question.  If a patient has a current complaint of abdominal pain it would not make sense for the physician to skip a GI exam, therefore possibly suggesting something was copied over from a different encounter.  Same thing with patient sex, Mrs. Jones could never have her prostate removed LOL. 

Once you find some examples of identical documentation between different patients or same patient....different encounters, use this as examples to show your physician what the issues are and risk to the practice.  

There is alot of supporting documentation on the AAPC's website regarding this risk area as well as many others such as, MGMA, AHIMA, PAHCOM, and many others.  you can even Google keywords and find many articles relating to this.  Check also your physicians specialty association website and your State Medical Society, as they also now have Practice Management/Coding Divisions to assist members and provide guidance and literature.


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