Ask any medical coder across the country and they will say that the biggest challenge that they are facing is not the absence of physician documentation; but it is that the documentation they are receiving is not adequate or rather incomplete, with many not even having the basic information that is necessary to assign accurate codes.

One of the main reason for this is the proverbial habit of the physician to capture only the information that they need to provide care. To be more elaborate, the physicians across the country are more concerned about capturing nuggets associated with evaluation, treatment and management of the health conditions that comes across their way. Everything that they do including the chart documentation that they provide is moulded around diagnostic phrasing and language, and certainly does not include any minute reference about codes.

Even though a large number of hospitals have implemented incremental steps including introducing clinical documentation programs to optimize documentation efforts of physicians, they haven’t seen much success. One of the main reason for this is the paucity of physicians. Whenever they feel that their patients are not gaining from efforts to modify documentation practices, they are quick to turn-back and continue their old habits. Another reason for this situation is the fact that these professionals are accustomed to being paid by their evaluation and management level, not their diagnoses.

What is Happening at the Practice

The superbill, or the encounter form, is one of the prime examples for inaccurate, unspecified and incomplete coding at a physician practice.

The condition for which the patient was treated can often be forcefully entered into those listed on the form or in some cases may not be captured at all. And even if the physician documents the condition, it may not be specific. For instance, the physician may only document conditions such as pancreatitis without specifying whether the condition is sclerotic, alcohol-induced, idiopathic, acute, or not indicating length of laceration or use of anaesthetic. Even the use of EHRs for diagnosis selection is not helping the cause. This is because, it is highly unlikely that the physicians will take that extra 30-60 seconds to go through the long list of choices that appears for the condition and select the most specific one.

The Solution

The only way one can increase the accuracy of documentation at a physician practice is by pushing some of the responsibility out to others in the practice. For instance, you can start at the front desk. At the time when appointment is made, and the health questionnaire is returned from the patient, personnel at the front desk can ensure that they capture the duration or date of onset, at bare minimum.

Also hiring a medical assistant (MA) can be of great help when it comes to increasing the accuracy of medical documentation.

Certified MAs are individuals who have completed a structured education program and are well-versed with medical terminologies, disease processes, medical coding regulation and anatomy of humans.

Leveraging their knowledge and understanding, MAs can easily talk to the patients, query them and glean valuable information which can often overlooked by physicians. All of these can go a long way in saving physician time, supplementing physician documentation efforts, and selecting a more specific code.

Let’s understand MA’s role with the help of an example of documentation for ICD-10 injury code elements. With a short interview with the patient, MA can capture key elements, which otherwise might be overlooked, such as:

  • The nature of the injury including information regarding “upper/lower” and laterality
  • Exact time when it happened to help physician ascertain whether it was an initial encounter for active treatment or other
  • Exact place where it happened
  • Patient status and the nature of work he was doing when the injury happened. For instance, if the patient was bitten by a cat, MA may attribute the patient status of other, but if the patient was bitten by the cat when he was holding it while administering injection by the vet, the status should be changed to an activity for income. The exact code for activity of “holding a cat” is the Y code for animal care.

The above instance is a prime example of the kinds of results that a bit of probing by the MA can bring in with regards to optimizing the documentation and medical coding process.

Let understand MA’s role with a reference to hierarchical condition categories, where the physicians generally fall short of maintaining the required level of specificity with regards to documentation. In this case, the MA can don the hat of a reviewer to assess minute details of the patient’s health questionnaire and capture conditions that the patient notes. In case the information provided by the patient is inadequate, these professionals can seek additional details regarding the condition, such as the time frame since the patient first contracted the condition, or previous records of treatment and medication.

What’s more, MA’s could also don the hat of a scribe and transfer all the findings that the physician dictates while examining the patient into EHR. This will not only save precious time of the physician but will also provide for a more comprehensive progress note in the EHR. In addition, these professionals can play a crucial part in determining medical necessities. Leveraging their knowledge of national and local coverage determinations, MAs can direct physicians to appropriately link the diagnosis with the in-office test and evade medical necessity denials.


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