Gastroenterology Coding Alert

Hint: Get others involved to deliver the best possible claim Helping your gastroenterologist become a detail-savvy documenter can lead to higher dividends -- especially when confronted with the history of present illness (HPI) element. Consider these six ways to beef up HPI documentation, and watch your coding become more accurate.
1. Get Information Up-Front Your appointment scheduler can get some details from patients when they call for an appointment. This can include things as simple as verifying the patient's address, phone number, insurance plan, and plan contact number. How this helps: Any information you can obtain beforehand and have in the computer system will streamline the process once the patient comes for her visit. That means less aggravation for her and for other patients who don't have to wait as long for your attention. 2. Let Your Hired Staff Pitch In Enlist help from your nurses or nurse assistants to get more thorough documentation. Some groups have their nurses obtain the patient's vitals and chief complaint when they take the patient to a room. How this helps: Your nurse is communicating with the patient, which helps her feel more comfortable and gives her the opportunity to voice concerns immediately. When your gastroenterologist comes in, he can summarize the information but spend his time with examination and treatment rather than obtaining general information. 3. Rely on Templates and Forms One of the easiest ways to ensure providers don't miss documenting any of the E/M visit components is to create templates they can follow. "I often see the review of systems (ROS) lacking," says Julee Shiley, CPC, CCS-P, CMC, a coding consultant at Critical Health Systems in Raleigh, N.C. "This should be included in the dictation template, or this information is sometimes included on an 'intake' form." Have your provider reference an ROS in the dictation and initial and date the form so the details can be included in the HPI. "The history is a three-of-three area," Shiley says. "Therefore, if you have an excellent HPI and problem-pertinent PFS (past, family and social history) but no ROS, the history component drops to the lowest level." How this helps: Using templates customized to your specialty can help physicians assign the correct level for visits, remind them to verify information they might have forgotten, and more. "Since we've gone to templates, it's gotten easier because they just have to make a check mark," says Kathy Campbell, CPC, a coder in Bloomington, Ind. Caution: Some experts warn against relying too much on templates, saying your physician could get in trouble with payers. If your practice uses templates, be sure the documentation is patient-specific. 4. Let Patients Document Conditions Some coders say that if you use [...]