As you train your staff on the changes that were recently made regarding evaluation and management coding it is very important to ensure that your staff understands the auditor’s perspective as well. There are four distinct portions of an auditor’s tool when evaluating the documentation guidelines for office/outpatient evaluation and management (E/M) services (99202-99215). The four distinct portions are diagnoses, data, risk, and calculation of medical decision making (MDM). In order to ensure that a provider’s progress note is complete in the auditor’s eyes the provider should ask themselves the following six questions to create the best chances of successfully meeting the auditors expectations:
Does my progress note contain a medically appropriate history and examination?
Were my diagnoses addressed appropriately?
Did I document all orders and data reviewed?
Were other professionals included in my documentation that I worked with?
Was an independent historian used?
Does the documentation support the level of risk I chose?
For the remainder of the article, I am going to dive deeper into each question above so that you, as providers are able to recognize insufficient areas in a provider’s E/M documentation when you perform a self audit to better your practice.
What follows is a very common scenario that helps demonstrate why proper documentation is essential in all personal injury cases, and what steps can be taken to ensure proper documentation occurs from the very beginning. Typically, following a car accident or slip and fall, a patient will present to the ER with complaints of “neck pain” only. However, the next day the patient might wake up with mid-back, and low back pain that radiates down the right leg, in addition to the original neck pain. The pain does not go away and gets worse, so they decide to make an appointment to come see their chiropractor.
The Problem Starts Here
When a new patient comes in for the first time, he or she typically starts the visit by completing a detailed history form. One of the first prompts is, “please tell us what hurts,” and there is a diagram that accompanies this question where the patient is asked to, “circle the areas that hurt.” More than likely the patient then puts or circles “neck, mid back, low back, and right leg.” The next question that typically follows the diagram asks, “When did your pain begin?” The patient then puts “4 days ago following my car wreck.” The potential problem for the treating chiropractor starts here. When the note is dictated it will more than likely read something to the effect of “New patient presents with history of neck, thoracic, and lumbar pain with radicular complaints, all of which began immediately after an MVA 4 days ago.”
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