Urology 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 your diagnosis codes 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, NY.

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 urologist complaining that she is unable to hold her bladder when doing physical activity. The urologist, in filling out the patient's form, checks a box for urinary incontinence. Later that afternoon, a different patient presents also complaining of the inability to control urination when the urge to urinate first occurs. Once again, the urologist 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 CPT 99212 (Established patient office visit) linked to the "not otherwise specified" incontinence code ICD-9 788.30.
 
The patients presented with different manifestations of the condition, however, and the diagnosis code for the first patient should have been 625.6 (Stress incontinence, female), while the correct diagnosis code for the second patient was actually 788.31 (Urge incontinence).
 
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 reinforces 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 Codes on a claim form or a template simply because you know 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 AAPC presentation "Documentation Templates ... 'Silver Bullets' or 'Smoking Guns.' "
 
But there is an equal number of cons to counter the pros of documentation templates, Gustin says. She says that templates may:
 

limit provider ability to free text information
 

promote documenting more than what was rendered
 

lead to "canned" or "cloned" documentation
 

be used inappropriately or misinterpreted by the user
 

promote noncompliant shortcuts (e.g., fill-in-the-blanks)
 

turn medical record progress notes into audit worksheets.

Gustin recommends that documentation always be date- and patient-specific and that the providers maintain sufficient documentation to justify diagnoses, admissions, treatments performed and continued care.

If You Must Use Templates ...

From a compliance perspective, make sure the template, whether paper or electronic, does not default to yes and no answers, DePasquale advises coders. And when purchasing software, be sure to have a compliance officer present because the "shortcuts" that appeal to your physicians may make every claim come out looking the same. If your documentation is the same, you're going to end up with the same diagnosis codes and the same procedure codes, and that's a problem, she says.
 
If you see cloned codes resulting from cloned documentation, tell your compliance officer or physician before risking a failed audit, DePasquale says.
 
Preprinted information may save time, but if it costs you reimbursement and coding compliance, it certainly won't be worth it.