Urology Coding Alert

Check your skills with identifying compliance pitfalls.

In the article “Leave the HPI Details to the Provider, But Leverage Nurse Help When You Can” on page 51, you learned about the importance of having your provider document certain portions of the encounter record. Now’s the time to test your know-how. Take a look at this scenario from a Maryland subscriber and see if you can spot the compliance risks in their documentation practices.

Review the Case

Scenario: With our outpatient office flow, we have our nurses and medical assistants (MAs) collect the history first and enter it into the electronic medical record (EMR) system. The information captured includes the chief complaint, review of systems, past medical, family and social history and also a detailed HPI. Then we, as the provider, enter the room and of course we take a history, do the physical exam, and make and changes as necessary in the HPI. We add to or subtract from the nurse/MA’s HPI notes as necessary.

The note will state that the nurse or MA entered the HPI and the provider’s signature appears at the end of the note to confirm that we have reviewed and agree with everything in our progress note. Is this acceptable documentation since we have an EMR? Test your know-how against the answers from the experts below.

Identify the Problems

This outpatient office’s staff is capturing some of the documentation incorrectly. The provider, not the patient or ancillary staff, should be documenting the HPI portion of the history and maybe even the chief complaint, depending on the payer.

Pointer: Auditors working with paper form documentation will pay attention to the handwriting in the chart. If the auditor can see clearly different handwriting and discern that the MA or someone else other than the provider wrote the HPI, she will likely discount all of the history. If there is no provider-documented HPI, then the visit is deemed not codeable. Things get a bit tricky with EMRs because an auditor cannot always tell who is actually putting in the HPI information, and because the entire encounter is electronically signed, auditors often assume the entire encounter was reviewed and/or performed by the provider. In reality, in most cases, the auditor has no way of knowing who put what information into the EMR.

But for compliant and correct practice, the provider himself should be documenting the HPI, along with, of course, the physical examination, and medical decision making sections. The exceptions are ROS, PMFSH, and vital signs. See Table 1 on page 53 for a chart you can hand out so that everyone in your practice is on the same page.