Wiki Is documentation of procedures in a separate note from E/M necessary?

[simmierae]

I work for an EHR vendor and we've had some ophthalmology clients complain that payer audits have dinged them for having minor procedures, such as injections, documented within the same encounter as an office visit. According to these clients, the audit results state the procedure has to be documented in a separate note. In my experience, this shouldn't be true for minor in-office procedures like an injection. If it were a surgery, they definitely would document that in an operative note separate from any E/M but... this is not the case.

Does anyone have guidance on documentation requirements for ophth or could anyone point me in the direction of any articles for clarification?

 

[thomas7331]

I agree with you - everything that is coded must be supported by documentation, but there is no requirement that the notes must be in any particular format or that certain codes must have a separate note. The notion is quite idiotic actually, because providers are not coders and without knowing how something is going to be coded, how would they know when they need to create a new note or not? Coders would always have to be sending notes back to providers to have the formatting changed if that was the case, which would be a shameful waste of time and resources.

I'd suggest talking with your clients and perhaps getting some examples of these audit cases. Review the auditors' letters and the medical records yourself to make sure you're getting the full story as to why the documentation has been found deficient - there may be other issues that the clients aren't understanding. But if in fact the auditors are penalizing the providers simply because of formatting, then the providers need to push back strongly against this. Auditors need to justify their audit citations with written guidelines - they can't just make up their own rules. They need to show you the payer's guidelines that specifically state this requirement and if there aren't any (which is likely the case - I've never run across a payer that required this) then those denials need to be reversed. If they won't back down on this, then the providers need to go to their network representatives or else evaluate whether the financial cost of dealing with these issues outweighs the benefits of remaining in the network or continuing to treat patients who have insurance through the payers who operate this way.

 

[amyjph]

These can be documented within the note. They don't require a formal and separate note. I am wondering if they might think it is due to it living within the visit note. However, in reality, they are really missing required elements of the documentation of the procedure? I agree with Thomas. You would definitely want to look at a number of these yourself to see what's really going on.
For an injection, as an example, the provider would still need to document consent, anatomic location, preparation of the site, name and dosage of drug, and patient reaction. They also need to show basic postoperative instructions. But, this can all be done within the visit note.

I have seen some practices with EHRs that automatically pull that part out and create a separate procedure note just so it's very clear but this is not required.

I could also see an overzealous auditor trying to use the fact that the minor procedures are in the "surgical section" and trying to say they need an "operative report" to justify a denial. Which should definitely be pushed back on.

 

[simmierae]

I agree with you - everything that is coded must be supported by documentation, but there is no requirement that the notes must be in any particular format or that certain codes must have a separate note. The notion is quite idiotic actually, because providers are not coders and without knowing how something is going to be coded, how would they know when they need to create a new note or not? Coders would always have to be sending notes back to providers to have the formatting changed if that was the case, which would be a shameful waste of time and resources.

I'd suggest talking with your clients and perhaps getting some examples of these audit cases. Review the auditors' letters and the medical records yourself to make sure you're getting the full story as to why the documentation has been found deficient - there may be other issues that the clients aren't understanding. But if in fact the auditors are penalizing the providers simply because of formatting, then the providers need to push back strongly against this. Auditors need to justify their audit citations with written guidelines - they can't just make up their own rules. They need to show you the payer's guidelines that specifically state this requirement and if there aren't any (which is likely the case - I've never run across a payer that required this) then those denials need to be reversed. If they won't back down on this, then the providers need to go to their network representatives or else evaluate whether the financial cost of dealing with these issues outweighs the benefits of remaining in the network or continuing to treat patients who have insurance through the payers who operate this way.

Thank you Thomas, this is what I was thinking as well about reviewing the audits and pushing back -- we're working on getting copies of the audits and I believe we will discover it is as one of the two scenarios you described - a different issue not yet understood or an issue worthy of a mighty push back. I appreciate your time and input!

 

[simmierae]

These can be documented within the note. They don't require a formal and separate note. I am wondering if they might think it is due to it living within the visit note. However, in reality, they are really missing required elements of the documentation of the procedure? I agree with Thomas. You would definitely want to look at a number of these yourself to see what's really going on.
For an injection, as an example, the provider would still need to document consent, anatomic location, preparation of the site, name and dosage of drug, and patient reaction. They also need to show basic postoperative instructions. But, this can all be done within the visit note.

I have seen some practices with EHRs that automatically pull that part out and create a separate procedure note just so it's very clear but this is not required.

I could also see an overzealous auditor trying to use the fact that the minor procedures are in the "surgical section" and trying to say they need an "operative report" to justify a denial. Which should definitely be pushed back on.

Thank you Amy, yes I'm in line with what you're thinking as well. With this feedback from you & Thomas, I have more confidence going to talk to clients to sort this out.

 

[Cheezum51]

As a provider, I think I'm somewhere in the middle on this question. I don't think that you have to have a totally separate note for the procedure but do feel that there should be a distinct section within the visit notes which are dedicated to the patient consent and operative note for the procedure. I would equate it with an I&R for a test. The I&R should be in its own separate section of the visit notes since it is paid for separately from the payment for the office visit and there are certain things which need to be in the I&R. The same could be said for a procedure which is done as part of the office visit.
An example would be for a patient who came in for a dry eye check and it was determined at the visit that the patient would benefit from having punctual plugs inserted and that was done in addition to the OV. The patient had two different services done at the same encounter, the OV and plugs insertion, and they deserve two different areas of documentation since you are going to be two separate fees, one for the OV and another for the plugs.
I believe that this is where the audit failures may be coming from.

Tom Cheezum, OD, CPC, COPC