Medical Records: Detail Physician Decisions in Every Chart

As a physician, you are aware of the confusing and complex world of medical coding. There are over 9,000 Current Procedural Terminology (CPT) codes - one for every type of healthcare service provided by healthcare practitioners or facilities. There are another 13,500 ICD-9 codes for medical diagnoses, plus more codes for medical supplies and for various health care settings. ICD-10 promises to further complicate matters, with an additional 5,000 codes.

If you assign a code for service which calls for too high a reimbursement, this is termed, “upcoding.” Assigning separate codes for services which are required to be billed under a comprehensive code is termed "unbundling." Either mistake can land you in serious trouble. It is perhaps for this reason, many physicians err on the side of caution, deliberately "down coding" as a hedge against benefits review audit scrutiny, and fraud/abuse enforcement activity.

But according to Dallas-based health lawyer, Cynthia Stamer, who recently discussed the topic with the North Texas Health Care Compliance Professionals Association, "getting the coding right is only half the battle." According to Stamer, “it used to be that medical decision-making would be clearly reflected in the patient’s chart.” However, “because we have moved to a complex system of CPT and ICD-9 codes, many physicians fall into the rut of believing coding replaces proper charting of medical decision-making."

What happens, when auditors review the chart” Stamer said, “is that there is no back-up documentation to support the chosen code. Even though the physician may have total recall of the patient and the medical decisions, physicians are victimized by the old adage, ‘if it didn’t’ get written down, it didn’t happen.’”

According to Stamer, this is where a skilled physician assistant can be invaluable. As medical coding becomes more and more specific, it is important to have a fresh set of eyes to ensure the basis for a physician’s decision makes its way into the chart. The irony seems to be, the more expert physicians become at coding, the less attention they pay to documenting the reasons for the chosen code.

Now, more than ever, it is imperative that patient charts reflect physician decision-making. Proper assignment of CPT and ICD-9 codes is only half the battle. The chart should reflect why the code was assigned. Kristy Welker is an independent medical coding consultant in San Diego who advises:

Practice Pointer #1: Do it right away. Aim to chart the medical decision-making process while it is fresh in your mind.

Practice Pointer #2: Make it legible. Writing it down won’t help, if no one can read it.

Practice Pointer #3: Beware of EHR “charting by exception.” EHRs often solve the legibility problem, but lead to another problem. Electronic recording is often set up to chart normal findings by default, and the physician is supposed to chart the abnormal findings. It is very easy for a physician get caught up in treating the patient, and forget to change the findings from “normal” to “abnormal.” Thus, a patient could be admitted because of chest pain, but the chart continues to reflect normal findings.

Practice Pointer #4: Be careful when making changes. Keep in mind that the medical record is a legal document and should never be altered. If you need to change or add to a patient record, write an addendum with the date of the revision.

Never write over an original entry or make it unreadable. Instead, if there is an error in a chart, draw a single line through the portion you’re correcting, keeping the original entry legible.

Sign and date the deletion, and state the reason for making the correction above or in the margin. Document the correct information on the next line or space with the current date and time, referring back to the original entry.

When correcting electronic records, follow the same principles: Track both the original entry and the correction with the current date, time and reason for the change. Any corrected record you submit must make clear the specific change made, the date of the change and the identity of the person making the entry.

Complete and accurate medical records improve the quality and efficiency of medical care and lower costs. Paying attention to charting basics not only protects your patients’ interests, but your own.