Pediatric Coding Alert

The difference between a clean claim and a denial usually comes down to one thing: documentation. Sometimes, your job as a coder is to identify whether the documentation in a patient record is complete and seek out additional information as needed. However, that’s not as easy as it sounds.

Why is documentation important? Payers and auditors look for supporting details that prove medical necessity and appropriate evaluation and management (E/M) levels. But patient medical records are not only critical to fair reimbursement; they also contain the information that will help determine future care.

Check out this helpful guidance for reviewing a patient record and some tips for effective and respectful provider queries.

Review CMS Guidelines for Proper Documentation

The Centers for Medicare & Medicaid Services (CMS) stresses that for a claim to be valid, there must be sufficient documentation to verify services performed were “reasonable and necessary,” and “supports the level of service” billed. In other words, if documentation is missing or insufficient, then there is no proof the reported codes accurately represent the encounter. Furthermore, if the documentation does not support paid claims, reimbursement may be considered an overpayment, and CMS could end up recouping the funds.

CMS dictates medical record notes should meet the following criteria:

1. Notes are complete and legible

2. Notes include:

• Reason for the encounter, relevant history, findings, diagnostic test results and date of service;
• Assessment, clinical impression or diagnosis;
• Plan of care; and
• Date and legible identity of the observer

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred

4. Past and present diagnoses are accessible to the treating and/ or consulting physician

5. Appropriate health risk factors are identified

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis are documented

7. The treatment and diagnosis codes (as well as the level of care) reported are supported by the documentation

(Source: https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/Downloads/ eval-mgmt-serv-guide-ICN006764.pdf).

Lean on E/M Notes

While CPT^® makes it clear that its E/M guidelines don’t establish documentation requirements or standards of care, it does remind coders of the main purpose of documentation. Proper documentation is meant to “support the care of the patient by current and future health care team(s),” according to the E/M Guidelines.

H&P is still important: It’s a common misconception that since history and physical exam haven’t directly contributed to office/outpatient E/M code selection since 2020, there is no reason to spend time documenting the history and examination. But exams and history are very much still part of the E/M services, and therefore must be documented. The E/M code descriptors tell you the service must include a “medically appropriate history and/or physical examination, when performed,” according to the guidelines. Remember, the purpose of a complete medical record is to provide thorough information for current and future healthcare teams.

Analyze the Medical Record With These Questions

The quality of the provider’s documentation allows coders to not only code with accuracy, but also to the highest specificity. It’s

important the provider get credit for all the work done. “When I’m analyzing a record, I like to use the acronym M.E.A.T., which stands for Monitor/Manage, Evaluate, Assess/Address, and Treat,” explains Keisha Wilson, CCS, CPC, SPMA, CRC, CPB, AAPC Approved Instructor, at KW Advanced Consulting, LLC in Brooklyn, New York. The acronym allows you to look at the patient record and see if all those elements have been addressed in the documentation by asking questions such as the following:

• Are there symptoms that show the progression or regression of a disease? (Monitor/Manage)
• What are the providers doing to evaluate this condition, and what are the tests ordered? (Evaluate)
• What tests has the patient had in the past/today? What were the findings? (Evaluate)
• How are the providers assessing and addressing the condition today? (Assess/Address)
• What is the plan for treatment? (Treat)

“If a provider keeps the term M.E.A.T. in mind, they will often have all the needed information for the coder to code the encounter without many queries,” Wilson says.

Recognize When to Query the Provider

Whenever there is inconsistent, missing, unclear or illegible documentation, query the provider immediately. To avoid unnecessary queries or incomplete queries that create more questions, read over the record carefully and look for gaps in the documentation relating to the following:

• Reason/intent of the visit.
• Reason/intent for tests and/or procedures.
• Status of established complaints.
  • Is the condition active or resolved? If active, is the condition stable, worsening, or not at goal? The answer could affect the assigned level of service based on the E/M complexity guidelines.
• Acuity of a diagnosis.
  • ​What are the medical needs to support? Is the condition acute, sub-acute, or chronic?

Coding alert: When cross-referencing codes, remember to look out for Use Additional notes. If additional information is required to report a code, that may be something you’ll need to include in your query.

Understand How to Query a Provider

There are fundamentally three types of queries. Which one or combination you use will be dependent on the situation and include the following options:

1. Y/N query: The query is written so the only answer can be “yes” or “no.”

2. Multiple-choice query: This question includes clinically significant and reasonable options as supported by clinical indicators in the record — understand though, at times, there may be only one reasonable option.

3. Open-ended query: This query allows a written response. Use when there are clinical indicators in the notes for a diagnosis or service, but the indicated diagnosis or service is not noted.

No matter which type of query you use, you should always use a consistent, compliant format. Additionally, state the facts simply and avoid making questions overly wordy. “Keep queries short and sweet and almost emotionless in tone. Don’t lead your providers to an answer either, as that won’t stand up in an audit,” Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, risk adjustment education specialist at Olympia Medical in Livonia, Michigan. Also, remember to document your queries and the provider’s response in the patient’s record in case anyone needs to reference the file later.

EMRs: Your practice may have query templates built into the electronic medical record (EMR) that can help you manage and maintain queries. If it looks like these templates have not been activated, reach out to the vendor. If an electronic query management system is not available, you can always create a standard text document to use and store queries.

For more information on queries, check out the AAPC blog: www.aapc.com/blog/85344-take-your-provider-queries-to-the-next-level/.