Primary Care Coding Alert

There are several reasons why documentation was a hot topic at HEALTHCON 2023. Documentation and good communication between coders and physicians are paramount to ensure coding accuracy, quality of care, and reimbursement.

The communication problems that can lead to inaccurate or incomplete notes often lie in the coder’s and provider’s unique approaches to documentation. “We can just do a little bit better about documentation. We can have more communication. Make sure physicians understand we’re not the enemy either,” said Jennifer McNamara CPC, CCS, CPMA, CRC, CGSC, COPC, AAPC Approved Instructor, director of education and coding at OncoSpark in Southpark, Texas during her HEALTHCON 2023 presentation, “Unpacking the Global Package.”

It’s easy for each party to fall into a mindset of one being right and the other being wrong because each prioritizes their own point of view. But the reality is that coders and providers are just coming from different places.

Aim for Accuracy

Clear and complete documentation ensures that you can assign the correct codes for the services provided and the diagnoses. You and your providers are pressed for time, but sometimes, all it takes is posting a clear list of documentation requirements.

Documentation refresh: The Centers for Medicare & Medicaid Services (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 provider.

      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.

Apply This Acronym to Your Queries

As you know, there is a degree of subjectivity in much of the medical decision making (MDM) table, based on the provider’s clinical opinion. However, this leaves a lot of room for error as coders try to turn evaluation and management (E/M) notes into E/M service codes.

For example, “risk, as defined by the AMA [American Medical Association] presents the nature of the problem, is based on the thoughts of the physician, and [is] based on the consequences of the problem. Physicians say, ‘I do that.’ But how does that translate to the medical record? How does that translate to the coder?” asked Stuart Newsome, CPCO, vice president of corporate & client experience at Alpha II, LLC in Montgomery, AL during his HEALTHCON 2023 presentation, “Risky Business: The Continuity of Risk and Revenue Impact of MDM for E/M.”

Risk is subjective, and a physician is constantly assessing risk, as it is an underlying consideration for addressing each element of the MDM table. Newsome suggests coders talk to providers and ask specifically that they use words like “low risk” or “high risk” so that their intent is clear. He also suggested the mnemonic “ALLSETDOC?” as coined by Pamela P. Bensen, MD, MS, FACEP. It stands for Acuity Links to Laterality, Site, Etiology, Type, Diagnosis, Occurrence, Comorbid conditions/complications, and Uncertainty. It’s an easy way coders can help physicians better communicate the subjectivity of their risk assessments, which can in turn lead to more accurately leveled E/M encounters.

Meet in the Middle

There is often a lot of emphasis on trying to get doctors to understand the coder’s perspective, but there should also be emphasis on coders stretching themselves to more easily reach the physician, according to CJ Wolf, MD, CPC, COC, CHC, educator and compliance executive in Salt Lake City, Utah during his HEALTHCON 2023 presentation, “Thinking Like an MD for E/M Services” in Nashville, Tennessee.

Coders have access to clinical terms and anatomy because of the in-depth chapter notes and guidelines in the ICD-10-CM codebook. That is a good place to start. Educating yourself on the clinical nuances of your specialty is not just about giving yourself the tools to interpret guidelines. It’s also about teaching yourself a little more about how physicians are trained to think so that you can ask the kinds of questions that get solid answers. “Doctors and coders have to meet in the middle and communicate. Coders are not doctors and vice versa. Be a good partner and communicator. Do your homework, study what they do, and ask questions,” said Wolf.

For example: Let’s say a patient is exhibiting cramping and weight loss but has normal vitals. There is no rebound tenderness and no heartburn or reflux symptoms. The patient suffers from high blood pressure, hyperlipidemia, pulmonary vascular disease (PVD), and coronary artery disease (CAD). The physician orders a colonoscopy and a mesenteric duplex ultrasound. There isn’t specific mention of why those tests are ordered, however.

The physician might think their thought process for ordering the mesenteric duplex ultrasound is obvious and that there is therefore no reason to write it down. However, if you know enough to understand what causes PVD and CAD, you can save yourself and the provider a lot of back-and-forth. If the patient is already experiencing plaque build-up in the lung and heart regions, the doctor might think his digestive system might also be affected, thus justifying the tests. Explaining to the provider (using this kind of basic clinical understanding) that payers need to see those thought processes might be more effective than simply asking why they ordered the tests, said Wolf.

Bottom line: Having a greater knowledge of clinical concepts is a good way to improve communication with your provider and yield more complete documentation. But you should not make coding decisions based on assumptions surmised from clinical knowledge.