Documentation Tips

[HoosierdaddyO]

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I guess this thread could be all encompassing anything from little things that you’ve noticed that could increase your RVUs, or litigation protective if you just documented it or documented it correctly. When do you actually do your charts?! do you finish them the day of the shift or you wait a couple days to try and look back to see the patients course before you actually sign the chart?

Personally speaking I found a few charts that I left by accident 4 or 5 days later to come back to see the patient course being quite different than I had anticipated (thankfully I got the dispo correct and admitted them lol), not only is this good for self QA but also is potentially useful when you do sign your notes... thoughts?!

 

[deleted859535]

Finish ASAP. Brief MDM on why the chest pain wasn't a dissection or PE, non-CT belly pain wasn't an appy, etc. Detailed NV and tendon exams on hand injuries. Don't get downcoded for stupid reasons -- be familiar with the kinds of charts that are 99285 and make sure you hit element requirements across HPI/HX/ROS/PE. Don't forget "critical care time" is probably more broad than many EM docs think it is.

 

[RustedFox]

"Patient indicated understanding of all instructions and need for timely follow-up in both word and in gesture."

 

[Groove]

I guess this thread could be all encompassing anything from little things that you’ve noticed that could increase your RVUs, or litigation protective if you just documented it or documented it correctly. When do you actually do your charts?! do you finish them the day of the shift or you wait a couple days to try and look back to see the patients course before you actually sign the chart?

Personally speaking I found a few charts that I left by accident 4 or 5 days later to come back to see the patient course being quite different than I had anticipated (thankfully I got the dispo correct and admitted them lol), not only is this good for self QA but also is potentially useful when you do sign your notes... thoughts?!

I finish 100% of my charts before I leave my shift and I always leave on time. I do short, brief, succinct MDMs. I see a lot of people repeat their HPI/ROS in their MDM and it just wastes time. For instance, my PE might look like this:

Acute resp failure, hypoxic on arrival, taken emergently to room 1, intubated, CTA with saddle PE, heparin gtt, ICU consulted, ACNP accepted for Dr. ICU.

I don't need to repeat all the stuff I put in my HPI because I already said it once. I don't need to comment that I reviewed and interpreted labs and imaging because I already clicked a box attesting to that fact earlier in the chart. I always document for a level 5 chart unless it's something silly like a suture removal. Better to have over documented and get down coded than under documented. Don't forget to document for CC on your ICU admissions. Most of them qualify.

I don't think it would be a very good idea to wait days to sign a chart just to see if you were "right" or if the patients bounced back. Just man up and call it for how you see it, then sign the note and be done with it.

Auditing your own admissions and following them while in the hospital is an excellent habit. I routinely review my admitted patients and follow the progress notes as well as run a monthly report on 5 day or less bounce backs.

 

[deleted859535]

I don't think it would be a very good idea to wait days to sign a chart just to see if you were "right" or if the patients bounced back. Just man up and call it for how you see it, then sign the note and be done with it.

Auditing your own admissions and following them while in the hospital is an excellent habit. I routinely review my admitted patients and follow the progress notes as well as run a monthly report on 5 day or less bounce backs.

Worth emphasizing these for sure. Intentionally delaying chart completion, in the event of a bad outcome, may or may not turn into a point of contention from a peer review / medicolegal standpoint depending on the details of the case and what is said in the note you then sign after you've reviewed a return visit and how things went then.

Strongly, strongly agree about chart review. This is one of the most efficient things an EM doc can do to be a better physician and better documenter.

 

[Groove]

I've got a little COVID pandemic inclusion in most of my notes that I'm not sure helps or not but I copied it from one of the hospitalists after seeing it in their note. It goes something like this:

This care is provided during an unprecedented national emergency due to the Novel Coronavirus (COVID-19). COVID-19 infections and transmission risks place heavy strains on healthcare resources. As this pandemic evolves, the Hospital and providers strive to respond fluidly, to remain operational, and to provide care relative to available resources and information. Outcomes are unpredictable and treatments are without well-defined guidelines. Further, the impact of COVID-19 on all aspects of emergency care, including the impact to patients seeking care for reasons other than COVID-19, is unavoidable during this national emergency..

Otherwise, just include documentation for common sense stuff like chest pain, belly pain, etc..

Atypical CP, exam consistent with costochondritis, constant for 1d therefore qualifies for single troponin rule out, EKG WNL, trop neg, imaging neg for acute path, PERC neg, HEART < 3, will Rx nsaids, rec f/u with PCP in 3 days, return precautions discussed.

Abd pain, benign exam, clinically consistent with enteritis, no leukocytosis, CRP neg, afebrile, Alvarado < 5 therefore appendicitis not suspected, no imaging indicated, will d/c on supportive meds, rec f/u with PCP in 3 days, return precautions discussed.

Blah, blah, blah.

 

[?atypical CP]

Worth emphasizing these for sure. Intentionally delaying chart completion, in the event of a bad outcome, may or may not turn into a point of contention from a peer review / medicolegal standpoint depending on the details of the case and what is said in the note you then sign after you've reviewed a return visit and how things went then.

Strongly, strongly agree about chart review. This is one of the most efficient things an EM doc can do to be a better physician and better documenter.

New attending here. I am a big fan of the delayed chart signature as a form of self review. This has increased my confidence in a variety of rapid dispositions. It has also shown me how inpatient teams often drop the ball and which consultants can be trusted to see the patient promptly.

I basically make a draft that is a complete note and formally sign it later. The draft appears like a regular note in the EMR. I rarely change anything after the fact.

 

[Groove]

New attending here. I am a big fan of the delayed chart signature as a form of self review. This has increased my confidence in a variety of rapid dispositions. It has also shown me how inpatient teams often drop the ball and which consultants can be trusted to see the patient promptly.

I basically make a draft that is a complete note and formally sign it later. The draft appears like a regular note in the EMR. I rarely change anything after the fact.

Yeah, but to what end? If you miss something and/or change your note, it's going to be a huge red flag for any attorney doing a chart review. That's the very first thing they'll notice and does the opposite of protecting you from potential suit. If you're rarely changing anything, then why wait several days to sign the note?

 

[deleted547339]

New attending here. I am a big fan of the delayed chart signature as a form of self review. This has increased my confidence in a variety of rapid dispositions. It has also shown me how inpatient teams often drop the ball and which consultants can be trusted to see the patient promptly.

I basically make a draft that is a complete note and formally sign it later. The draft appears like a regular note in the EMR. I rarely change anything after the fact.

Uhh, don’t do that.

 

[deleted547339]

I've got a little COVID pandemic inclusion in most of my notes that I'm not sure helps or not but I copied it from one of the hospitalists after seeing it in their note. It goes something like this:

This care is provided during an unprecedented national emergency due to the Novel Coronavirus (COVID-19). COVID-19 infections and transmission risks place heavy strains on healthcare resources. As this pandemic evolves, the Hospital and providers strive to respond fluidly, to remain operational, and to provide care relative to available resources and information. Outcomes are unpredictable and treatments are without well-defined guidelines. Further, the impact of COVID-19 on all aspects of emergency care, including the impact to patients seeking care for reasons other than COVID-19, is unavoidable during this national emergency..

Otherwise, just include documentation for common sense stuff like chest pain, belly pain, etc..

Atypical CP, exam consistent with costochondritis, constant for 1d therefore qualifies for single troponin rule out, EKG WNL, trop neg, imaging neg for acute path, PERC neg, HEART < 3, will Rx nsaids, rec f/u with PCP in 3 days, return precautions discussed.

Abd pain, benign exam, clinically consistent with enteritis, no leukocytosis, CRP neg, afebrile, Alvarado < 5 therefore appendicitis not suspected, no imaging indicated, will d/c on supportive meds, rec f/u with PCP in 3 days, return precautions discussed.

Blah, blah, blah.

alvarado score is garbage. I’d be afraid to reference it. I feel like if youre wrong, that would be a big point of contention.

 

[deleted206819]

Here's a good list of critical care procedures and conditions that you should have on your phone or at your computer. What we do day in and day out becomes the norm after a while and you tend to forgot that it is CC level care outside of the ED.

 

[RustedFox]

Uhh, don’t do that.

Seconded.

 

[namethatsmell]

Don't allow a scribe or EMR template to take you into the gray area of billing fraud with regard to ROS and PE. If you're seeing an ankle sprain and including heme/lymph in the ROS you're doing it wrong...and the zealous CMG billers won't care....

 

[pkwraith]

Depending on what your EMR is, it's pretty easy to generate a report of your prior patients to review without delaying your actual note. It's a really bad reason to delay your documentation. A) it will likely effecting your billing to delay the chart and someone's going to start talking to you about that, B) medicolegal, documenting after you are aware of later complications throws a lot of question into your documentation.

 

[turkeyjerky]

Don't allow a scribe or EMR template to take you into the gray area of billing fraud with regard to ROS and PE. If you're seeing an ankle sprain and including heme/lymph in the ROS you're doing it wrong...and the zealous CMG billers won't care....

We always worry about this, but is anyone aware of any actual physicians who've been audited for something like this?

 

[thegenius]

I finish 100% of my charts before I leave my shift and I always leave on time. I do short, brief, succinct MDMs. I see a lot of people repeat their HPI/ROS in their MDM and it just wastes time. For instance, my PE might look like this:

Acute resp failure, hypoxic on arrival, taken emergently to room 1, intubated, CTA with saddle PE, heparin gtt, ICU consulted, ACNP accepted for Dr. ICU.

I don't need to repeat all the stuff I put in my HPI because I already said it once. I don't need to comment that I reviewed and interpreted labs and imaging because I already clicked a box attesting to that fact earlier in the chart. I always document for a level 5 chart unless it's something silly like a suture removal. Better to have over documented and get down coded than under documented. Don't forget to document for CC on your ICU admissions. Most of them qualify.

I don't think it would be a very good idea to wait days to sign a chart just to see if you were "right" or if the patients bounced back. Just man up and call it for how you see it, then sign the note and be done with it.

Auditing your own admissions and following them while in the hospital is an excellent habit. I routinely review my admitted patients and follow the progress notes as well as run a monthly report on 5 day or less bounce backs.

I need to learn to do this. Charts suck time out of me.

 

[thegenius]

"Patient indicated understanding of all instructions and need for timely follow-up in both word and in gesture."

What does that mean, in gesture? To let the reader know they weren't just staring at you or something?

 

[RustedFox]

@thegenius

Simple. When I ask them if they understand; they generally reply with an audible agreement and a nod.
If they don't nod, I ask them again, and generally myself give a thumbs-up or something.
They respond in kind.

This way, I can say: "I asked them if they understood. They indicated that they did in more than one manner of communication; so they must have meant it." This is especially useful in AMA/high-risk discussions.

 

[namethatsmell]

We always worry about this, but is anyone aware of any actual physicians who've been audited for something like this?

Yes.

 

[BoardingDoc]

Yes.

details? Non-identifying is obviously fine, but was this person audited because they were doing a bunch of shady ****? Or as far as you're aware was this person just nailed because they claimed to do a bigger ROS than they actually did?

 

[thegenius]

I finish 100% of my charts before I leave my shift and I always leave on time. I do short, brief, succinct MDMs. I see a lot of people repeat their HPI/ROS in their MDM and it just wastes time. For instance, my PE might look like this:

Acute resp failure, hypoxic on arrival, taken emergently to room 1, intubated, CTA with saddle PE, heparin gtt, ICU consulted, ACNP accepted for Dr. ICU.

I don't need to repeat all the stuff I put in my HPI because I already said it once. I don't need to comment that I reviewed and interpreted labs and imaging because I already clicked a box attesting to that fact earlier in the chart. I always document for a level 5 chart unless it's something silly like a suture removal. Better to have over documented and get down coded than under documented. Don't forget to document for CC on your ICU admissions. Most of them qualify.

I don't think it would be a very good idea to wait days to sign a chart just to see if you were "right" or if the patients bounced back. Just man up and call it for how you see it, then sign the note and be done with it.

Auditing your own admissions and following them while in the hospital is an excellent habit. I routinely review my admitted patients and follow the progress notes as well as run a monthly report on 5 day or less bounce backs.

So do you write your MDM once you have dispo'ed the patient?
In your example above, it appears you write it after you are done with the patient.

I'm used to writing the MDM in stages, or, you know...what I think after I leave the room and my differential and then my final impression.

As you can see, I spend 10x the amount I should on my MDMs

 

[namethatsmell]

details? Non-identifying is obviously fine, but was this person audited because they were doing a bunch of shady ****? Or as far as you're aware was this person just nailed because they claimed to do a bigger ROS than they actually did?

A few people got flagged by a CMS watchdog group at a CMG I used to work for. The docs themselves were not trying to do anything shady. Rather, the CMG scribes were told to always put in full ROS/PE templates and only pair them down if/as the doc requested...and you can guess what happened next. That shop was bonkers busy and there was rarely enough time to finish notes during your shift. So those who didn't take the extra time to fix those parts eventually got love letters from the watchdog letting them know that something like >80% of their visits were billed as a level 5. This was courtesy of the lovely CMG billers who were able to run wild by having a massive ROS/PE to go with a scribe generated HPI and a reasonable MDM. None of the docs ended up in trouble for that, but it was apparently a warning shot from CMS via the 3rd party watchdog. There have been posts about similar stuff on EM Docs in the past as well.

 

[BoardingDoc]

A few people got flagged by a CMS watchdog group at a CMG I used to work for. The docs themselves were not trying to do anything shady. Rather, the CMG scribes were told to always put in full ROS/PE templates and only pair them down if/as the doc requested...and you can guess what happened next. That shop was bonkers busy and there was rarely enough time to finish notes during your shift. So those who didn't take the extra time to fix those parts eventually got love letters from the watchdog letting them know that something like >80% of their visits were billed as a level 5. This was courtesy of the lovely CMG billers who were able to run wild by having a massive ROS/PE to go with a scribe generated HPI and a reasonable MDM. None of the docs ended up in trouble for that, but it was apparently a warning shot from CMS via the 3rd party watchdog. There have been posts about similar stuff on EM Docs in the past as well.

Interesting. I don't know enough about coding, but I would have thought that the diagnoses listed at the bottom would have prevented that sort of thing. Even if I did a full PE/ROS on every single patient I see, I doubt that the diagnoses that I list would let 80% of them get coded as a lvl 5 chart (unless the diagnosis is irrelevant? Again, I don't code my own charts).

 

[namethatsmell]

Interesting. I don't know enough about coding, but I would have thought that the diagnoses listed at the bottom would have prevented that sort of thing. Even if I did a full PE/ROS on every single patient I see, I doubt that the diagnoses that I list would let 80% of them get coded as a lvl 5 chart (unless the diagnosis is irrelevant? Again, I don't code my own charts).

I'm not sure either. But I learned from these guys that by only putting in stuff that's actually pertinent/legit in the ROS/PE you effectively take back the reins from a very aggressive and/or creative coder. So if you only have 4 systems on PE, you can rest assured it's not going to bill as a 5.

 

[thegenius]

A few people got flagged by a CMS watchdog group at a CMG I used to work for. The docs themselves were not trying to do anything shady. Rather, the CMG scribes were told to always put in full ROS/PE templates and only pair them down if/as the doc requested...and you can guess what happened next. That shop was bonkers busy and there was rarely enough time to finish notes during your shift. So those who didn't take the extra time to fix those parts eventually got love letters from the watchdog letting them know that something like >80% of their visits were billed as a level 5. This was courtesy of the lovely CMG billers who were able to run wild by having a massive ROS/PE to go with a scribe generated HPI and a reasonable MDM. None of the docs ended up in trouble for that, but it was apparently a warning shot from CMS via the 3rd party watchdog. There have been posts about similar stuff on EM Docs in the past as well.

This seems to be a billing and coding problem.

There is no way you can bill level 5 for a routine ankle sprain in a healthy person no matter how detailed your HPI, ROS, and physical exam are.

 

[RuralEDDoc]

Interesting. I don't know enough about coding, but I would have thought that the diagnoses listed at the bottom would have prevented that sort of thing. Even if I did a full PE/ROS on every single patient I see, I doubt that the diagnoses that I list would let 80% of them get coded as a lvl 5 chart (unless the diagnosis is irrelevant? Again, I don't code my own charts).

Diagnosis is not what determines a complexity level - workup intensity and MDM does. That’s intentional, so you don’t spend an hour working up an 80 year old dizziness then paid nothing for finally diagnosing nonspecific dizziness. I agree with previous posters that you should only document what you did and what was appropriate. Don’t do a level 5 ROS and physical exam for a simple chart. It lets someone else bill whatever they want under your name.

 

[thegenius]

Diagnosis is not what determines a complexity level - workup intensity and MDM does. That’s intentional, so you don’t spend an hour working up an 80 year old dizziness then paid nothing for finally diagnosing nonspecific dizziness. I agree with previous posters that you should only document what you did and what was appropriate. Don’t do a level 5 ROS and physical exam for a simple chart. It lets someone else bill whatever they want under your name.

That makes sense, that's why I put in differential diagnoses because I feel that imparts how complex a patient is.

But I still think I write too much.

@Groove - how would you write an MDM for this hypothetical patient?
24 yo healthy guy comes in for lower abdominal pain, vomiting, and feeling ill for 1.5 days. Temp 99.2, HR 105, BP 120, RR 20, exam looks kind of ill, mild lower abdominal tenderness b/l. Labs WBC 14.4, Lactate 2.1, rest of standard labs are normal. CT shows non-specific enteritis. He received 2L, toradol, zofran, and bentyl. He felt better, passed PO, vitals were better and you discharge him.

I would somehow find a way to write a whole paragraph for this guy. I suspect I'm not doing it the right way.

 

[wareagle726]

A few of my favorite tidbits that I'm sure a lot of you know backwards and forwards and maybe a few you don't...

-Know your Marshfield Criteria. Great article on ALiEM with a chart.

-Understand that charting for RVUs is completely different than charting for the lawyer

-Have a list of pre-written DC justification/instructions, Ddx, Procedures, etc... and load them into "hot texts." All mine are something like ...CVL, ...DCinstruction, ...AMADC

-Only document what you actually did in the ROS/PEx. The RVU difference in 99283 and 99285 is not worth getting audited

-Whatever EMR you use, learn the tricks of hot texts, macros, etc...

-I generally put a detailed HPI and my initial MDM with plan, then as things change I write in the re-exam portion with updates. I put in the important PEx findings then return later and add the template on top of it, changing what is needed. I can finish these notes hours later if needed without really having to remember anything other than the past medical/surgical/social hx later.

-Don't revise a note past an hour or two beyond signing it, all the metadata for every click you made is available for lawyers.

-The actual ICD-10 diagnosis doesn't determine your level of care, it does help to justify it though. There's really no such thing as a "diagnosis that doesn't bill" as far as I'm aware.

-CC time/notes are under-utilized by far in the ED. Know what qualifies and take the extra 30 seconds to justify it appropriately. It helps to have a phrase something along the lines of "This patient has a high likelihood of organ failure or death without my focused care and intervention."

-Make your procedure notes as friendly as possible. Have them pre-fabbed to only need a few changes each time. Example(my "...lac" hot text):
Laceration Repair Note
Date/Time: wareagle726, MD
Indication: Laceration as described above
Provider: My name
The appropriate timeout was taken. Verbal consent was obtained. The area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved using 5cc of 1% lidocaine with epinephrine. The wound was copiously irrigated with 100ml/cm of normal saline under pressure. The wound required a single layer closure. *number* 4-0 monofilament interrupted sutures were placed. Hemostasis was achieved. The wound was dressed with a non-adherant dressing. There were no complications and the patient tolerated the procedure well. Post-procedurally the area was re-examined and distal/surrounding sensation, motor, and vasculature was unchanged from pre-procedure exam.
EBL < 10mL
Total Time for Procedure: 15 mins

So all I have to change is the number of sutures. Obviously there are circumstances where things will need to be edited.

-Some cerner specific things:
-The comments section/text box on the "Follow-Up" tab is the last thing to print on the DC paperwork which the patient has to physically sign before DC. If you have a good set of followup instructions that would be presented to a court with the patient's signature directly below it
-Under the hot text section, create a new phrase and insert a token(the tab second from the right in the top right, looks like a little + sign) for a bunch of different automatically populated features. One of my favorites is automatically importing radiology reports. You may have to search when you click on the tokens icon to find it and it's under something different on every system.
-Have pre-completed "General Medical Problem" that you save a ROX, PEx, imported labs and vitals, DC instructions, etc... that you use for everything. All you have to do is change the title. Sure the chest pain note or the abdominal pain note have different pre-selected HPI and DDX/MDM sections but you can easily add those.
-The little green bar in the bottom left is a sham other than to remind you if you forgot to enter your ROS or PEx. It doesn't know how to interpret your MDM/Risk which is the most important part
-You don't actually have to click all those boxes in HPI. As long as you have the 4 components of the HPI(any 4 of OLD-CARTS) freetexted the others don't matter from a billing standpoint if your coders are actually doing any work.

 

[deleted836128]

- I use macros for physical exams to save time, but I remember to unclick anything I didn’t actually examine. Don’t document anything you didn’t do, ever.
- If I give the patient a sedating med in the ER I always document who’s taking them home. If I prescribe a sedating med like a narcotic I put a blurb in there about “Sedation warnings given, and patient verbally understood these warnings.” They will get the same warning in their patient education.
- Obviously document a good neurovascular and tendon exam for hand injuries. Isolated at the MCP, PIP and DIP joints, passively and against resistance.
- When I dispo a patient I think, if this patient died in 24 hours what would one question about my care based on this chart? I address any of those things before I dispo a patient and make sure my chart reflects that.
- Always have a chaperone present for pelvic exams / testicular exams and document the name of the chaperone. This is to protect against the crazies. I once had a son accuse me of anally probing his elderly mom (I am a female provider by the way) when assessing for rectal tone when she had back pain and new onset urinary incontinence and leg numbness. Yeah.
- Get your charts done by the end of the shift. Sign them and be done. If you must make a change add it in as an addendum without editing the actual chart you already signed.
- Document important names and phone numbers of contacts (like the patient’s POA if they are demented) in the chart if they are heavily needed for the care of the patient. I usually put the name and number in the history source at the top of the chart. Incredibly helpful for the next people who take over care of the patient because often times it is not documented elsewhere.
- Just get in the habit of asking all patients about tobacco / drugs / alcohol and surgeries. That way you make it a habit so you’ll never get downcoded on an otherwise perfect level 4 or 5 chart.
- Always address triage note discrepancies in the chart. ALWAYS. If the triage note says that the patient has abdominal pain and they don’t, I will always say something like “The triage note mentions abdominal pain but the patient firmly denies this; he or she has not experienced any abdominal pain.”
- Don’t forget to document critical care! Bone up on what qualifies as CC; you’d be surprised.
- Always address abnormal vitals. Before I discharge a patient I always go in and import the vitals and make sure nothing is amiss.
- Document your ambulation tests. If I have a back pain patient who initially can’t walk, they get a road test before they go and then I can say they walked safely. For my dyspneic patients I send home, it’s nice to get an ambulatory pulse ox of 98-99 percent on room air.
- Don’t put careless crap in the chart. Won’t help you when you go to court. A demented 95 year old doesn’t have “no history limitations.” A baby is not alert and oriented times four. A baby doesn’t have an appropriate mood and affect. A pregnant woman technically doesn’t have a nondistended abdomen with no organomegaly.
- Always document a thorough exam for trauma patients. I see people clicking “Normal range of motion, no tenderness, no swelling” in general but for a trauma I actually document out both upper extremity parts and lower extremity parts to show that I actually examined each part.
- Document your repeat belly exams.
- Paint a picture. One of my favorite older docs taught me this. “The patient was resting comfortably on the stretcher, texting on her phone and eating Cheetos.” “The child was looking around the room curiously, moving freely about the stretcher, and laughing.”
- Never forget to acknowledge incidental findings on imaging like lung nodules. Document you told the patient, gave a copy of the results and told them to see their doc for outpatient work up. The incidental finding should also go in as a diagnosis. Also - if it is a big one I will even put in the follow up instructions “Please see your doctor about your blah blah blah noted on the CT scan. You will need further work up.”
- Give specific return precautions - WRITTEN. For undiagnosed belly pain, sometimes I tell patients to come back in 24 hours if not feeling better and write that in their follow up instructions.
- Document every phone call to another provider that you make. I even do that with the hospitalist when they call me to ask about an admission I sent them.

 

[Cinclus]

Diagnosis is not what determines a complexity level - workup intensity and MDM does. That’s intentional, so you don’t spend an hour working up an 80 year old dizziness then paid nothing for finally diagnosing nonspecific dizziness. I agree with previous posters that you should only document what you did and what was appropriate. Don’t do a level 5 ROS and physical exam for a simple chart. It lets someone else bill whatever they want under your name.

I was under the impression that what you click under the "complexity" area of the MDM determines how high of a level a chart can be billed, or are the 80+% of charts I have been attempting to appropriately downcode not having that happen?

 

[deleted547339]

I was under the impression that what you click under the "complexity" area of the MDM determines how high of a level a chart can be billed, or are the 80+% of charts I have been attempting to appropriately downcode not having that happen?

Level of the chart is dictated by a lot of things - how extensive is your history, PMH, ROS, PE and MDM. You should be able to google a table pretty easily. You should submit a bill in accordance with the type of visit. You should document to the level of visit. Putting a 10 point ROS on an ankle sprain doesn’t make it a level 5 because the complexity isn’t there. The complexity is the hardest thing to make objective and where you could get hit in an audit if you overfill. But a 4 point ROS on an otherwise level 5 visit will get you downgraded. Charting what you haven’t done or submitting a bill not supported by the documentation is fraud. If a biller submits and ankle sprain as a level 5 because you have 4 elements of hpi, 10 pt ROS, PMH/PSH, 8 systems examined under your name, it’s still your fraud. That’s why someone suggested only putting 4 systems reviewed when its not a level 5 visit.

 

[Groove]

alvarado score is garbage. I’d be afraid to reference it. I feel like if youre wrong, that would be a big point of contention.

Why not? It's a fun little CDR and it's been validated. Low scores don't need imaging because they don't have appendicitis and high scores don't need it either because they do.

The Alvarado score for predicting acute appendicitis: a systematic review - PMC

The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination ...

www.ncbi.nlm.nih.gov

The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain - PubMed

Diagnostic IV, therapeutic IV.

pubmed.ncbi.nlm.nih.gov

Plus, just look at the score. You do this every time you evaluate abdominal pain. It's part of your gestault and a helluva lot more fun to type and put in my MDM. I can't count the number of crusty old surgeons that have been tickled pink that I knew what an Alvarado score was...

CDRs aren't there to tell you what to do with the patient, they're there to show that you thought about a specific diagnosis. This becomes valuable when you've got attorneys, patients or other non medical personal reviewing your chart trying to see if you practiced anything remotely standard of care. Then they hand these charts over to an "expert" which many times can be any specialist. We've got a plaintiff attorney in town using a retired general surgeon to review OB, EM and pediatric cases to determine if they have "merit". You just really never know who's reading these things. It "sounds" better quoting a relatively decent CDR. You're never going to have a suit that's being reviewed by a panel of FOAMed/Ivory tower academic emergency docs pontificating on negative predictive values and sensitivities of particular CDRs.

Funny story, but true. I trained an APC years back to start using Alvarado's if she was going to not image belly pain. I told her to make sure it was less than 3 and a negative CRP. Anything else gets spun up. I didn't think much of it at the time, I was just trying to come up with any CDR that I felt would reduce missed appy 's and wouldn't require me evaluating every single one of their belly pain patients. Well, she ends up becoming a really good EM NP and goes on to become a PCP in town. She sent a guy over for a STAT CT scan and had an Alvarado score in the note. Notoriously grumpy surgeon sees it and goes bonkers that an NP knew what an Alvarado score was.... He starts laughing, picks up the phone and congratulates her on an excellent assessment and on her Alvarado score. He goes "Well Ms. EM NP, according to your Alvarado score, I didn't even really need to send them to CT scan now did I??!". After she told me that, I didn't have the heart to tell her that it's a CDR that's rarely used in the world of EM. LOL, true story.

 

[Groove]

So do you write your MDM once you have dispo'ed the patient?
In your example above, it appears you write it after you are done with the patient.

I'm used to writing the MDM in stages, or, you know...what I think after I leave the room and my differential and then my final impression.

As you can see, I spend 10x the amount I should on my MDMs

I keep the note up to date throughout the entire ED course. When I discharge a patient, I literally finish the note before I put in the discharge order. It only takes a few seconds. So, when the house goes up (Cerner), the chart turns green and is signed. For admitted patients, I have everything up to date before I call the admitting doc because I know they're going to be reading my note as we're talking about the admission. After they accept, I update the note with the consult and disposition information and sign it. Now, you're probably thinking that this must delay my dispositions but I routinely have the fastest or 2nd fastest LOS and don't use a scribe.

The secret is knowing what charts to spend time on... I hardly type anything in the MDM on a level 3 or less. I save it for charts that are level 4 or up, have increased liability risk (belly pain, chest pain, MVC, etc..) or where their ED course was complicated, etc..

As for leaving on time, I stop picking up patients an hour or 1.5 hours before it's time for me to leave. If there's someone on the board that my partner can't pick up because he's swamped, I walk around and screen them and dump in orders for him or the incoming doc. About 20% of the time, I find that it's someone I can disposition really quickly and I'll put my name on them.

That makes sense, that's why I put in differential diagnoses because I feel that imparts how complex a patient is.

But I still think I write too much.

@Groove - how would you write an MDM for this hypothetical patient?
24 yo healthy guy comes in for lower abdominal pain, vomiting, and feeling ill for 1.5 days. Temp 99.2, HR 105, BP 120, RR 20, exam looks kind of ill, mild lower abdominal tenderness b/l. Labs WBC 14.4, Lactate 2.1, rest of standard labs are normal. CT shows non-specific enteritis. He received 2L, toradol, zofran, and bentyl. He felt better, passed PO, vitals were better and you discharge him.

I would somehow find a way to write a whole paragraph for this guy. I suspect I'm not doing it the right way.

PT with clinical enteritis, no acute path on CT, mild leukocytosis with non diagnostic lactatemia, sx improved after IV meds and fluids, AVSS, NAD, tolerating PO, no high risk features. Will d/c on supportive meds and +/- empiric abx for possible infectious enteritis. Rec f/u with PCP in 3 days, return precautions discussed.

 

[Brigade4Radiant]

Depends on how aggressive your coder is CMS doesn’t care what your ROS is or if you click the same thing every time. They care if you overbill all of your charts you shouldn’t have 80% of your visits as a level 5.

 

[CajunMedic]

I have MDM templates for admission and discharge:

"[age] y/o [gender], with history and physical as documented above. Considered X, here's why it's not X. Considered Y, here's why it's not Y, etc. It's XXX and why. Discharged in stable condition, with directions to F/U w/xyz, or return to ED if symptoms worsen, or become worrisome. Diagnosis, prescriptions, treatment plan, and follow up discussed with patient (and family) at bedside. Opportunity to ask questions was given (all were answered to patient and family satisfaction/none were asked). Patient verbalizes understanding."

Admission is as above but ends with: "Diagnosis, treatment plan, necessity for admission discussed with patient (and family) at bedside. After discussion with on-call physician, pt (admitted/placed in observation) to the (ICU/Hospitalist/Surgery/etc.) service.

I'll modify them for specific situations.

- Paint a picture. One of my favorite older docs taught me this. “The patient was resting comfortably on the stretcher, texting on her phone and eating Cheetos.” “The child was looking around the room curiously, moving freely about the stretcher, and laughing.”

I do that as well, especially with reassessments. I use .currentdate in Cerner to timestamp my reevaluations. I also use it to document when I talk to a consultant and what they said: "14:02:51-Spoke w/Dr. Schmuckatelli from the hospitalist service, he stated they will see the patient for admission"

 

[deleted547339]

Why not? It's a fun little CDR and it's been validated. Low scores don't need imaging because they don't have appendicitis and high scores don't need it either because they do.

The Alvarado score for predicting acute appendicitis: a systematic review - PMC

The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination ...

www.ncbi.nlm.nih.gov

The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain - PubMed

Diagnostic IV, therapeutic IV.

pubmed.ncbi.nlm.nih.gov

Plus, just look at the score. You do this every time you evaluate abdominal pain. It's part of your gestault and a helluva lot more fun to type and put in my MDM. I can't count the number of crusty old surgeons that have been tickled pink that I knew what an Alvarado score was...

CDRs aren't there to tell you what to do with the patient, they're there to show that you thought about a specific diagnosis. This becomes valuable when you've got attorneys, patients or other non medical personal reviewing your chart trying to see if you practiced anything remotely standard of care. Then they hand these charts over to an "expert" which many times can be any specialist. We've got a plaintiff attorney in town using a retired general surgeon to review OB, EM and pediatric cases to determine if they have "merit". You just really never know who's reading these things. It "sounds" better quoting a relatively decent CDR. You're never going to have a suit that's being reviewed by a panel of FOAMed/Ivory tower academic emergency docs pontificating on negative predictive values and sensitivities of particular CDRs.

Funny story, but true. I trained an APC years back to start using Alvarado's if she was going to not image belly pain. I told her to make sure it was less than 3 and a negative CRP. Anything else gets spun up. I didn't think much of it at the time, I was just trying to come up with any CDR that I felt would reduce missed appy 's and wouldn't require me evaluating every single one of their belly pain patients. Well, she ends up becoming a really good EM NP and goes on to become a PCP in town. She sent a guy over for a STAT CT scan and had an Alvarado score in the note. Notoriously grumpy surgeon sees it and goes bonkers that an NP knew what an Alvarado score was.... He starts laughing, picks up the phone and congratulates her on an excellent assessment and on her Alvarado score. He goes "Well Ms. EM NP, according to your Alvarado score, I didn't even really need to send them to CT scan now did I??!". After she told me that, I didn't have the heart to tell her that it's a CDR that's rarely used in the world of EM. LOL, true story.

Eh, everything I’ve read on the test characteristics aren't acceptable to me. If I’m not scanning a belly pain, I just document “could be early appy, but don’t think so. Counseled patient to return with any new or worsening symptoms as well as symptom persistence for 12 hours.”

Also, the number of times I think esr or crp are helpful approaches 0.

 

[Groove]

Eh, everything I’ve read on the test characteristics aren't acceptable to me. If I’m not scanning a belly pain, I just document “could be early appy, but don’t think so. Counseled patient to return with any new or worsening symptoms as well as symptom persistence for 12 hours.”

Also, the number of times I think esr or crp are helpful approaches 0.

CRP is part of the AIR score which I sometimes will drop in with the Alvarado, again...just to provide a related CDR showing that I considered appendicitis.

Evaluation of the Appendicitis Inflammatory Response Score for Patients with Acute Appendicitis - PMC

Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose ...

www.ncbi.nlm.nih.gov

https://www.mdcalc.com/appendicitis-inflammatory-response-air-score

CRPs come back really quickly for me. I'm primarily using the CRP and CDRs on the really melodramatic patients with belly pain where I know they don't need imaging and want a note that can support my decision to discharge without a CT. I'm a big fan of CDRs in the note. I think it looks good and presents the reader with a "system" that is published/studied (+/- evidence based) and that was applied to support a clinical decision. It implies that other physicians also use that system to make similar clinical decisions and may or may not be a CDR that an expert witness (plaintiff or defendant) might be familiar with. You never know... I don't document for my colleagues, I document for all the other potential readers. I like to think it protects me somewhat but who knows.

 

[namethatsmell]

This seems to be a billing and coding problem.

There is no way you can bill level 5 for a routine ankle sprain in a healthy person no matter how detailed your HPI, ROS, and physical exam are.

Exactly. No sane doc would code an ankle as a 5. A CMG biller with little skin in the game may try it if the note allowed. It may get rejected, but their view is probably nothing ventured, nothing gained. All they care about is numbers and $.

Diagnosis is not what determines a complexity level - workup intensity and MDM does. That’s intentional, so you don’t spend an hour working up an 80 year old dizziness then paid nothing for finally diagnosing nonspecific dizziness. I agree with previous posters that you should only document what you did and what was appropriate. Don’t do a level 5 ROS and physical exam for a simple chart. It lets someone else bill whatever they want under your name.

Precisely.

 

[GeneralVeers]

Exactly. No sane doc would code an ankle as a 5. A CMG biller with little skin in the game may try it if the note allowed. It may get rejected, but their view is probably nothing ventured, nothing gained. All they care about is numbers and $.



Precisely.

Right. You can submit a visit as a level 5.....as long as you did what you said and it could still be rejected. Better to upcode the chart, and get that denied, than bill at a lower level. At least there's a chance you'll get the higher billing code.

 

[wareagle726]

Right. You can submit a visit as a level 5.....as long as you did what you said and it could still be rejected. Better to upcode the chart, and get that denied, than bill at a lower level. At least there's a chance you'll get the higher billing code.

I agree. It's really easy to bill a level 5 chart with a routine ROS that covers a lot of things with minimal questions and a doorway PEx. It would be really hard for them to audit you and say that the patient didn't have non-icteric sclera, speaking normally, etc... Technically we aren't "billing" or "coding" anything...period. I can put all the info in the chart and then it is the coder's job to not bill a splinter as a level 5. We are just there do document what we did and why/how sick they were.

Now if you deliberately put a critical care note in there that's a different story lol

 

[Groove]

This is the only thread where I've heard of anyone getting audited and even then it doesn't appear that much came of it. Our coders seem to be pretty savvy as even though I code out a level 5 the majority of the time, when I review the codes at the end of the month, they seem to be appropriately submitting them as a fairly balanced distribution of 1-5s.

 

[deleted859535]

This is the only thread where I've heard of anyone getting audited and even then it doesn't appear that much came of it. Our coders seem to be pretty savvy as even though I code out a level 5 the majority of the time, when I review the codes at the end of the month, they seem to be appropriately submitting them as a fairly balanced distribution of 1-5s.

Similar with ours. I almost always chart to a 99285 except when it's obviously pointless to do all that -- the ankle sprain, dental pain, etc -- and while I'm heavily 99284/99285/99291 in some months more so than my partners, our billers seem to do a good job not going overboard.

 

[deleted547339]

I agree. It's really easy to bill a level 5 chart with a routine ROS that covers a lot of things with minimal questions and a doorway PEx. It would be really hard for them to audit you and say that the patient didn't have non-icteric sclera, speaking normally, etc... Technically we aren't "billing" or "coding" anything...period. I can put all the info in the chart and then it is the coder's job to not bill a splinter as a level 5. We are just there do document what we did and why/how sick they were.

Now if you deliberately put a critical care note in there that's a different story lol

Yes, BUT you are responsible for what is billed on your behalf.

 

[thegenius]

I think when you sign agreements with these billing companies they usually place risk of fraud on the billing company, right?

If you code your own chart, and fraud is found, then you are liable
If your billing company codes your chart, and fraud is found, then the company is liable.

(That's my interpretation at least)

 

[thegenius]

"Patient indicated understanding of all instructions and need for timely follow-up in both word and in gesture."

I put that in a macro. Using it now.

 

[namethatsmell]

I think when you sign agreements with these billing companies they usually place risk of fraud on the billing company, right?

If you code your own chart, and fraud is found, then you are liable
If your billing company codes your chart, and fraud is found, then the company is liable.

(That's my interpretation at least)

I no longer work for that CMG but when I did I'm pretty sure the docs were liable for how charts were billed. Crazy, eh? Who knows if it would hold up in court should things get that far, but still unnerving.

 

[southerndoc]

A few people got flagged by a CMS watchdog group at a CMG I used to work for. The docs themselves were not trying to do anything shady. Rather, the CMG scribes were told to always put in full ROS/PE templates and only pair them down if/as the doc requested...and you can guess what happened next. That shop was bonkers busy and there was rarely enough time to finish notes during your shift. So those who didn't take the extra time to fix those parts eventually got love letters from the watchdog letting them know that something like >80% of their visits were billed as a level 5. This was courtesy of the lovely CMG billers who were able to run wild by having a massive ROS/PE to go with a scribe generated HPI and a reasonable MDM. None of the docs ended up in trouble for that, but it was apparently a warning shot from CMS via the 3rd party watchdog. There have been posts about similar stuff on EM Docs in the past as well.

I received one of those letters as did the majority of docs in my practice. Not sure what they meant. We use an independent company to code and bill for us that get paid by the chart and not by the level of billing. Our practice is exceptionally sick, and when we received the letters we felt the charts were accurately billed as level 5's. Therefore, nothing has changed with our practice. If CMS thinks a high-risk chest pain should be a level 4, then that's ridiculous.

 

[bbc586]

I think billing and protective documentation (review from your medical director, hospital peer review committee, an attorney, judge/jury, etc....) are two totally different things.

Extensive writing about this on medmalreviewer.com, almost all on EM cases.

Good starting case: Case 9: Abdominal Pain – MedMalReviewer

There's also a documentation template and rubric to help guide as well.

(Disclosure: self promotion)

 

[RustedFox]

I think billing and protective documentation (review from your medical director, hospital peer review committee, an attorney, judge/jury, etc....) are two totally different things.

Extensive writing about this on medmalreviewer.com, almost all on EM cases.

Good starting case: Case 9: Abdominal Pain – MedMalReviewer

There's also a documentation template and rubric to help guide as well.

(Disclosure: self promotion)

Interesting website.
I bookmarked it, and am very interested in watching it grow.

 

[BoardingDoc]

I think billing and protective documentation (review from your medical director, hospital peer review committee, an attorney, judge/jury, etc....) are two totally different things.

Extensive writing about this on medmalreviewer.com, almost all on EM cases.

Good starting case: Case 9: Abdominal Pain – MedMalReviewer

There's also a documentation template and rubric to help guide as well.

(Disclosure: self promotion)

I just read the case you linked. This case is a colossal **** up. The first doc probably should have admitted the patient. The second doc absolutely should have done so and killed the patient. This doesn't seem to be much of a teaching point except to maybe make everyone here who isn't a terrible doctor feel good about that fact.