In the Age of Electronic Medical Records (EMR), many have seen notes become bloated with extensive histories, medication lists, old labs, and radiology that may not have been obtained at the present visit or even be pertinent. Ironically, many physicians do not document some of the work they actually did for the present visit and this can adversely affect their Level of Service (LOS) so that the code billed is not reflective of the work they performed.

In the outpatient/clinic setting, physicians perform a great deal of behind-the-scenes work, outside of the patient's presence, to be able to diagnose and treat their patients appropriately. They review the patient's records, talk with other providers, order and review tests, and coordinate care. Most of these activities cannot be counted if the provider is billing based upon time because they occur before or after the patient's visit. It is very important for physicians to describe the work they do in their notes so that the work may be captured when the note is coded by the elements of History, Exam, and Medical Decision Making (MDM).

I have reviewed tens of thousands of notes and I have talked with hundreds of providers in the past nine years as a coder and a compliance specialist. I continually see that certain items of MDM (Diagnosis, Data, Risk) typically go undocumented or unlabeled, and therefore, unused when determining a LOS. This is the list of questions I ask physicians when I meet with them:

• I see that you have a number of patient complaints listed in your HPI but they are not documented in your A&P. Did you address any of these issues during the visit? If they did address them during the visit, it is important to list them because it shows that they were dealing with more than one health issue which may increase the level of MDM, and possibly, the LOS.
• Are you performing a record review? I often find the record review summary integrated within the HPI. When I see many specific dates, lab findings, and other detailed information in the HPI, I query the physician about the source of the data. If the record review is not separated from the HPI, the information may be attributed to HPI only and s/he may not get credit in the MDM section for this work.
• Do you review the patient's images or slides yourself? Not all providers do this but many specialists do view the images or slides themselves, but if they do and it is documented, it can elevate the level of MDM.
• Do you talk with the radiologist or pathologist?
• Do you order additional records?

Is your patient on a drug therapy requiring intensive monitoring for toxicity? Many drugs require that a patient undergo frequent laboratory work to determine if the dose or drug itself is having adverse affects on the patient's health. "Intensive" is not defined and is open to interpretation but most would not consider testing for toxicity once or twice a year to be intensive.

Your physicians may balk at having to document more than they are now. EMR templates can be set up with prompts or phrases that would be routinely used. We use the Epic system and we have created phrases that the physician can select when appropriate such as:

• This patient is on requiring intensive monitoring for which I have ordered labs to check toxicity levels.
• I have performed a Record Review. Pertinent details include:
• I independently reviewed the patient's images. My findings are:

Does it really make a difference in the LOS if the physicians document all of this work that they are doing? YES - not for every visit, but for some, it could make a big difference. Let's take a look at a Hematology/Oncology example:

A New Patient comes in with a newly diagnosed cancer, for which the patient has few symptoms and is doing well, to discuss treatment options. The physician documents a Comprehensive History and Exam, orders labs, pulls in other lab work and radiology from the EMR system, and discusses the need for chemotherapy. This would be a 99204. A Moderate?!?! Yes, the documentation shows:

• Diagnosis: New Problem Needing Work-Up (4 pts - High Complexity)
• Data: Lab and radiology review (2 pts - Low Complexity)
• Risk: Prescription drug management (Moderate Complexity), New Problem Uncertain Prognosis (Moderate Complexity)

I suspect this documentation doesn't tell the whole story. Let's say we meet with this physician and ask all the questions listed above. The physician tells us that he did a record review and looked at the patient's images himself. With this new information and improved documentation:

• Diagnosis: New Problem Needing Work-Up (4 pts - High Complexity)
• Data: Record Review (2 pts), Independent Review of Images (2 pts), Orders additional Lab work (1 pt) for a total of 5 pts = High Complexity
• Risk: Prescription drug management (Moderate Complexity), New Problem Uncertain Prognosis (Moderate Complexity)

This changes the LOS to a 99205 because the documentation shows all of the additional data that the physician reviewed. The original documentation showed a Low Complexity for Data whereas the improved documentation showed a High Complexity.

I often find that physicians are not up-coding so much as they are under-documenting the service that they performed.

Erin Andersen, CPC, CHC
Compliance Specialist, Oregon Health & Science University
Erin Andersen has worked in coding and compliance since 2003-performing chart audits and educating providers, coders, and staff on coding and billing. Erin seizes any opportunity to expand her coding knowledge and is an active member of the Rose City chapter in Portland, Oregon. She is a member of the AAPC Chapter Association (AAPCCA) www.aapc.com.