ED Coding and Reimbursement Alert

Question: What is the legality of returning charts to the physician to amend the documentation to reflect the appropriate E/M level and care she provided? I know this practice is standard, but are there any laws governing it?


Kansas Subscriber

Answer: Your first step in determining the legality of this practice should be to check with the policies of your hospital. Hospital policy will very likely give you information regarding the guidelines about signing and dating the late note and tell you how long after the patient encounter the physician can add the note.

From a compliance perspective, if you ask the emergency physician to add the note or addenda simply to make the documentation support a certain code, be aware that certain Medicare carriers will view such late notes or addenda with disfavor.

For example, adding more review-of-systems elements just to achieve enough for 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status ...) may trigger that scrutiny.
 
In general, you may return records if they represent an -incomplete medical record---meaning they don't accurately reflect the presentation and care of the patient. Most carriers frown on simply sending records back for additional documentation elements.

Best practice: Stay in step with the hospital's time period regarding the time line--or develop your own, follow the policy and be prepared to defend or explain it in an audit.