Posted: 12/01/2011

Editor’s Note: Healthcare is serious business, and the repercussions of deficiencies in medical documentation can be considerable. Nurse attorney Carolyn Buppert examines the landscape of medical record auditing — for a variety of purposes — and offers practical suggestions to improve your documentation in this 3-part series. Part 1 illustrates the potential consequences of even the slightest, but critical, omissions in medical record documentation.

Judgment Day: Medical Record Review

Clinical care is judged on medical record documentation. The progress note is what justifies payment for medical services. Moreover, it is the progress note that supports or fails to support a clinician and his or her employer when a question arises about the necessity or competency of care.

Consider these 2 scenarios:

Critical Gap in Documentation

Scenario 1: Minor omission from progress note leads to denial of payment. A physician conducted a follow-up visit with a 78-year-old man with a history of secretion of inappropriate antidiuretic hormone (SIADH). Documentation was as follows:

“Patient and wife in to review the evaluation for SIADH. His sodium is now corrected to 136 with water restriction. CT shows old right frontal infarction which he denies having any symptoms of. There is mild cerebral atrophy consistent with age. CT of chest shows 2-mm nodule in right apex, possible granuloma. CT abdomen unremarkable.”

Impression:

1. SIADH improved
2. Pulmonary nodule, small
3. Frontal cerebrovascular accident, asymptomatic
4. Rule out macrovascular disease

Plan:

1. Monitor pulmonary nodule with repeat CT scan in 6 months
2. Pulmonary medicine consult
3. Neurology consult; patient will schedule
4. Carotid duplex study
5. Continue fluid restriction

Complicated patient, right? The physician billed Medicare for a CPT 99215. The physician’s documentation was audited and Medicare denied payment for the visit. The physician wrote to Medicare, stating “I billed a higher level of service because of the complexity of the above problems plus the length of time consulting with the patient and his wife. In addition, I reviewed his radiographs with a radiologist.”

Medicare still denied payment. Why? The clinician did not include the time spent counseling the patient. If a clinician spends at least 20 minutes of a 40-minute office visit (or at least 18 minutes of a 35-minute hospital visit) discussing laboratory results, prognosis, treatment options, instructions for treatment, importance of compliance, reduction of risk factors or providing other patient and family education, the clinician may bill the highest level office or hospital visit, based on counseling time spent. Had the physician noted that 40 minutes was spent with the patient discussing the prognosis and treatment plan, Medicare would have reimbursed the physician approximately $137 for an office visit or, if the visit was conducted with an inpatient, approximately $97. Without those few words specifying the time spent, Medicare reimbursed nothing at all.

If the physician had cared to appeal Medicare’s decision, he might have argued that his note justified payment for a lower level office visit; however, because he documented medical decision-making but not history or examination, his note would have justified only the lowest-level visit.

Patient Follow-Up Oversight

Scenario 2: Lack of documentation of follow-up makes for difficult defense. A 47-year-old woman with a 22-pack-year smoking history fell in the shower during Memorial Day weekend. She visited an emergency department and a chest radiograph was made. The radiograph showed 2 fractured ribs and a poorly defined 2-cm alveolar density in the right lung apex. The radiologist wrote: “This may be caused by acute pneumonia, but close follow-up is advised.” The emergency department staff referred the patient back to her primary care provider, who was a nurse practitioner (NP).

A few days later, the patient visited the NP, who ordered erythromycin for 10 days and recommended a repeat chest radiograph in 2 weeks. The repeat radiograph showed “nearly complete resolution of previously documented right upper lobe density.” The radiologist made no recommendation for additional follow-up. The NP made a brief note that was not entirely legible but may have read “will get radiograph” however, no further radiographs were ordered that year. The NP recalled having told the patient that a follow-up radiograph was needed.

The NP saw the patient in July for screening blood tests. The patient’s liver function tests were elevated. In August, the NP recommended follow-up of elevated liver function tests with a gastroenterology consult. The NP also attended to some of the patient’s health maintenance needs. The patient did not see the gastroenterologist as recommended by the NP. The practice’s receptionist called the patient in October to remind her to follow through with the gastroenterologist. The patient said she would. Nothing was documented about radiographs.

The following July, the patient visited the NP, complaining of hemoptysis. A chest radiograph showed complete opacification of the right lung. The diagnosis was lung cancer. The patient died within the year.

The patient’s husband sued the NP, the NP’s collaborating medical doctor, and the radiologist, alleging failure to diagnose lung cancer. Expert witnesses for the radiologist stated that the cancer that killed the patient was probably not the density seen on chest radiograph the previous summer. Expert witnesses for the patient stated that the cancer that killed the patient probably was the lesion detected on the radiograph the previous summer.

Eventually, all defendants except the NP were dropped from the suit. An internist working for the plaintiff testified at deposition that the NP should have repeated the radiograph until it was absolutely clear or until a diagnosis was made and managed. The internist also testified that it was the NP’s responsibility to advise the patient of the serious consequences of failing to follow through with further tests. The NP maintained that she told the patient to return for a radiograph and followed up by telephone, but no documentation could be found in the medical record to support her position. The suit was settled in favor of the patient.

Faulty Documentation Is All Too Common

In scenario 1, the physician could have avoided a denied charge simply by noting the time spent with the patient. An internal auditor could have easily seen that the physician’s documentation did not correspond with the requirements for CPT 99215 and the physician could have made an addendum. In scenario 2, the NP should have documented her instructions to the patient about the need for a follow up radiograph. Furthermore, if she or office staff members made numerous attempts to reach the patient to follow up with her, those efforts should have been documented. An internal auditor could have noted the deficiencies in the documentation and reminded the NP that additional follow-up was necessary, as well as documentation of follow-up or attempts to follow up.

In each of these examples, losses could have been avoided. However, hospitals and medical practices rarely analyze documentation unless an unfortunate incident occurs. When that happens, records are scrutinized with a critical eye.

This author has audited documentation at hospitals and found medical record entries with these problems:

• Large illegible sections, including signatures. If Medicare audits a record and an entry or signature is illegible, they will demand repayment of money already paid. Furthermore, if the note becomes evidence in a malpractice case, poor handwriting damages the credibility of the writer.
• A clinician stated that a hospitalized patient’s chief complaint was “Doing well.” Payment for hospitalization and for physician services is contingent on medical necessity. If the patient is “doing well,” why does he need to be hospitalized? The note should indicate why the patient needs to be in the hospital each day. Rather than writing “doing well,” the clinician should state something like: “Breathing is improved over yesterday, although patient is still struggling during exertion.”
• Clinician described an assessment or impression as “doing well.” This vague comment can create the same problems as when used for “chief complaint.”
• Components of the necessary elements of medical work for the billed Current Procedural Terminology (CPT) code were missing. If all required components of medical work — history, examination, and medical decision-making — are not documented, payers will pay only the CPT code for which the documentation meets requirements. If one of the required elements — examination, for example — is omitted from a new patient visit, the visit cannot be billed as a new patient visit.
• Clinician did not note follow-up to or resolution of a problem identified a day earlier. If the patient’s condition gets worse and the patient has a permanent injury or diminished life span and sues, the clinician and his or her employer will have a difficult time defending the lack of attention to an identified problem.
• Clinician documented inexact vital signs (eg, afebrile, BP normal). Subsequent caregivers may be unable to understand the significance of these notations or changes in the patient’s status because the baseline values are not precise.
• Clinician used nonstandard abbreviations, which could be misinterpreted by subsequent providers.
• Clinician noted a complaint of pain but did not fully describe it (location, duration, onset, aggravating factors, alleviating factors, quality, and quantity). Subsequent caregivers have no starting point on which to base improvement or change for the worse.

The problems noted above can lead to denial of payment for the daily visit, denial of payment to the hospital for the stay, confusion among subsequent caregivers, and difficult defense if a lawsuit is filed or a complaint is made to a professional board.

Documentation: What Is the Purpose?

Medical record documentation has 4 objectives:

1. To show that the service was medically necessary;
2. To justify billing the service at the level billed;
3. To demonstrate that the standard of care was met, if needed, to defend against an action for malpractice; and
4. To assist clinicians who follow in performing subsequent care.

Multiple entities outside the hospital or practice may review or audit medical record documentation, for variety of reasons. The next part in this series will take a closer look at these entities, and answer the question: “What are they looking for?”