Wiki E&M overdocumenting?

[AR2728]

I'm seeing a lot of level 4s and level 5s for my Internal Med physician. While his patients are usually more complicated-here is the exact issue I'm running into. He uses an EMR he is documenting in the HPI every diagnosis the patient has regardless if he is the treating physician. I have a patient with more than a dozen documented diagnosis, most which state followed by DR. xyz, meds per Dr. xyz in the HPI. Then in the Assessment he is again listing every diagnosis, however, on the plan he may only personally address 4 of those that he is following himself. I was under the impression that he should not receive extra credit for conditions that he is only menitoning. I understand some may affect the patient's care and therefore, they are more complex. However, some examples of what I am seeing are HDL followed by Dr. x-stable. Re-occuring headaches listing 4 HPI elements then stating saw Dr. y, given med now stable, follow up with Dr. y. Chronic allergic sinusitis listing 4 HPI again and stating given med by Dr. z follow with him.

Am I correct in my thinking, that these extra 10 diagnosis not being treated should not be counted toward the level of care?

I have the samilar issue with my General Surgeon. He mentions in the CC and HPI patient presents for 1 week follow up for axillary abscess. Then on the assessment and plan he will throw in the patient had irritable bowel found on last scopes, stable on current meds follow up scope in 5 years and wants to receive credit for this. Again, shouldn't something regarding these extra issues be addressed in the HPI in order to count towards the visit.

I would appreciate feedback on this. I would love to have some documentation to provide to my physicians as well.

 

[StaceyAlte]

I would listen to the audio tomorrow. The live is 12:00pm Central or you can listen to the On Demand webinar 1 hour following the Live broadcast. It's titled "Documentation: How to Learn What the Docotr Didn't Note." Right in the introduction it talks about too much documentation & even if it's documented it may not get reported. I'm looking forward to this webinar! I hope it's informative!

 

[JDV7980]

Wow! Too much documentation, thats not something you hear all th time, I suppose it is always better than not enough but I do see how that would be an issue, we have a doctor that just keeps repeating everything over and over for like 10 pgs. That's alot to fumble through when coding it, but you do know that you do not need to report every single diagnosis. You may be able to count some of the diagnoses as part of the MDM... perhaps, because of medication Interferences and/or complications???

Also, we have to remember that the documentation was not originally for coders, billers etc. It was strickly for the care of the patient and so that the physicians could know what the patient was being treated for... now it's all about what the insurances want to see in order to pay for services. The older docs (& some younger ones) seem to take issue with this...lol and I don't blame them.

In the example of the general surgeon, was the irritable bowel mentioned in his ROS? I have letters stating that ROS and HPI can be used interchangibly (I do not know how to attach) but I'm sorry, I do not know about "assessment and plan" issue but I am with you, I think that this item should be mentioned within the History/ROS part of the documentation.

 

[MnTwins29]

Also keep in mind that cloning or copy and paste functions are the main cause of overdocumentation and the OIG has that in the work plan now. Even though he may not have originally seen the patient this sounds like this physician is guilty of doing this.