Anesthesia Coding Alert

Hint: Thorough encounter notes are your key to success.

Much of your coding depends on your providers’ encounter notes – and how thoroughly they document details. If their documentation is minimal, confusing, or fraudulent, your practice could be in hot water — in more ways than one. 

Make sure your clinicians’ documentation techniques will pass muster with these expert tips.

The Good News: It’s Never Too Late to Start Improving 

Now’s the time to assess clinicians’ documentation skills, says Arlene Maxim, RN, founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. Under ICD-10, clinicians will need to beef up their documentation, she says.

“Documentation will make or break this process,” says Maxim, because ICD-10 will require a higher degree of specificity. Assessing documentation practices now allows your group to begin improving their efforts before the added pressure of the ICD-10 deadline arrives.

Clinical documentation is the foundation of every health record, said Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga. Clinicians may collect documentation only once, but others will use it many times so it’s important to make every effort to prevent it from being misunderstood.

Clinicians need to think about how often others will use and access their documentation in the future, Steed said during the recent AudioEducator -sponsored audioconference “Clinical Documentation Improvement.” This critical information is needed for patient care.

Documentation and coding go hand-in-hand, Steed said. The “coder needs high quality documentation to determine coding quality and accuracy.”

Focus on These 7 Criteria

Steed outlined seven criteria for quality clinical documentation. Consider how your clinicians’ documentation stacks up in each area and provide help in making the changes needed to better support coding choice.

1. Legibility: Documentation should be readable and easily deciphered. A lot of handwritten documentation isn’t legible or decipherable, Steed cautioned. Rushed or careless documentation may cause other problems.

Legibility includes being able to read the name and title of the clinician completing the documentation, Maxim says.

This is an especially important aspect of good documentation, Steed said. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient’s condition.
• Jeopardized reimbursement.
• Denied payment.
• Loss of legal appeals.
• Serious patient injury.

2. Reliability: Is the documentation trustworthy? Based on the diagnoses, is the documentation reliable? Does it support the rationale for the diagnoses and for medical necessity?

The reliability is not just related to the assessment, but with every single visit note. Most denials and down coding occur when visit notes don’t support the codes you report.

3. Precision: Clinical documentation must be accurate, exact, and strictly defined. Increased detail generally means greater accuracy in documentation, Steed said.

The degree of specificity in documentation that will be necessary with ICD-10 will challenge even the most experienced clinicians, Maxim says.

4. Completeness: Good documentation fully addresses all concerns in the record, and includes appropriate validation. 

5. Consistency: Documentation shouldn’t be contradictory. Are there conflicting statements in the record? Are there conflicting opinions between providers that have not been clarified? Make sure any inconsistencies are addressed.

This is where the coordination of services comes into play, Maxim says. Many times a contradiction occurs when there is a lack of communication between the disciplines. “Get everyone on the same page.”

6. Clarity: Documentation should be unambiguous. Vague documentation that does not totally describe a patient’s condition won’t support the services your practice provides.

7. Timeliness: Documentation must be up to date to help ensure optimal patient treatment.