General Surgery Coding Alert

You have to base your ICD-9 coding on your physician's documentation, but that doesn't mean you have to accept your physician's form of documentation.
 
Documentation templates may seem like a coding dream come true, but if the diagnosis codes you're billing are looking eerily familiar, you may be basing your coding on "cloned documentation" - a coding and compliance nightmare.
 
If your documentation template allows your physician to check one box for "yes" and another for "no," and it's not individualized for each system, you're at risk of coding from cloned documentation, says Melissa DePasquale, CPC, CCS-P, CHCC, director of coding and compliance for Community Care Physicians in Latham, N.Y.

What to Look For

Use this example to help you distinguish whether your templates are resulting in identical diagnosis codes and documentation for patients with different conditions.
 
On Tuesday morning, a patient presents to the general surgeon complaining that she has abdominal pain in the lower right quadrant. The physician, in filling out the patient's form, checks a box for abdominal pain. Later that afternoon, a different patient presents also complaining of abdominal pain, but in the upper right quadrant. Once again, the surgeon checks the same box. Both patients' charts are submitted to the coding and billing department, and the coder assigns both patients an office visit code of 99212 linked to the "unspecified site" abdominal pain code 789.00. The patients presented with different manifestations of the condition, however, and the diagnosis code for the first patient should have been 789.03 (Abdominal pain; right lower quadrant) while the correct diagnosis code for the second patient was actually 789.01 (Abdominal pain; right upper quadrant).
 
According to a September 2002 "Medicare Sentinel" publication by TrailBlazer Health Enterprises LLC (a Virginia carrier), "One of the probe reviews found several physicians whose office records indicated they used a computerized documentation program that 'defaults' information from previous entries to successive progress notes." The carrier goes on to explain that the default information produced documentation that was identical for multiple patients' physical exams.
 
Cigna Medicare warns of the dangers of medical record cloning and tells coders what proper documentation should look like. Cigna states in a Medicare Bulletin that "All documentation in the medical record should be patient-specific. Cloning of documentation will be considered misrepresentation of the medical-necessity requirements for coverage of services." According to Cigna, you will be denied reimbursement if the carrier discovers cloned documentation.
 
But don't assume you can never have patients with similar diagnosis codes on separate claims forms - that's fine as long as the patients actually have the given condition. Remember, you should never place an ICD-9 code on a claim form or a template simply because you know that the insurer will automatically consider the procedure medically necessary. Be sure that all of the information on your template and in your chart is documented elsewhere in the patients' files.

Weigh the Pros and Cons

The pros of templates include streamlined documentation, standardized information, improved legibility, improved continuity and quality of patient care, clarified documentation requirements, and simplified audits, says Georgette Gustin, CPC, CCS-P, CHC, in her April 2003 American Academy of Professional Coders conference presentation "Documentation Templates ... 'Silver Bullets' or 'Smoking Guns.' "
 
But there is an equal number of cons to counter the pros of documentation templates, according to Gustin. She says that templates may: