Physiatry Practice Management Resources

The Conditions are a good guide for requirements for physician documentation in a patient medical record. These are the minimum documentation guidelines for hospitals who participate in the Medicare program. They generally state that every patient record must contain documentation of:

1. a physical examination (performed not more than 7 days prior to admission or within 48 hours of admission)
2. a health history (elicited from the patient not more than 7 days prior to admission or within 48 hours of admission)
3. admitting diagnosis
4. results of all consults
5. appropriate findings by clinical/other staff involved in the patient’s care
6. complications, hospital acquired infections, unfavorable reactions to drugs and anesthesia
7. properly executed informed consent forms for procedures and treatments
8. all practitioners orders, nursing notes, reports of a treatment, medication records, radiology and laboratory reports, vital signs
9. discharge summary which includes: outcome of hospitalization, disposition of case and provisions for follow up care
10. final diagnosis with a completed record within 30 days of discharge

In the OIG Compliance Guidance, the OIG refers specifically to certain documents within the record that may be referenced for correct and complete coding. These include:

1. Reasons for patient encounter
2. History and physical
3. Progress notes
4. Treatment plan
5. Referrals and consultations
6. Patient education
7. Recommended follow up care
8. Documented rationale for services
9. Documentation supporting medical necessity
10. Test results
11. Relevant health risk factors
12. Prescriptions

In addressing physicians’ and other clinicians’ documentation in a patient’s health record, the following characteristics should be reviewed:

1. Legibility

   Illegible documentation can be reason to deny payment for services as well as to provoke possible quality issues with the care of the patient.

2. Completeness

   To determine completeness of documentation, you need to ask the following questions:

   1. does the information flow logically
   2. are there any information gaps
   3. are there abnormal test results without explanatory documentation
   4. is there conflicting documentation in the patient record
   5. are there any required reports that are missing
   
    
3. Timeliness

   Timeliness is prescribed by regulations and laws. For example, certain documents need to be in the patient’s record within 24 or 48 hours. Timeliness of documentation affects the quality of patient care. If important information that other clinicians treating the patient need to know to take proper care of the patient is missing - there could be disastrous results.

4. Authentication

   Physicians’ (and other clinicians treating the patient) signatures are required on all their own documentation. As well, physicians need to co-sign and often document more detailed information along with documentation for other clinicians whose work they are responsible for. This applies, for example, to residents and interns in teaching facilities.

5. Corrections and Alterations

   It is important to address making corrections and alterations in patient records. Because of human error, it is inevitable that clinicians will make mistakes. In general, when an author makes an error, it should be corrected in the following manner:

   1. put a line through the documentation made in error (the line should allow the documentation to show through - don’t smear it out or cross it out completely)
   2. write the word error above the line
   3. initial and date just after the word error
   4. finally, erasures, whiteout or other cover-up techniques should never be used in patient medical records - they call in to question the credibility of the entire record.

The OIG defines assumption coding as "assuming (and coding) from the clinical evidence on the patient’s record that the patient has certain diagnoses in the absence of the physician’s explicit documentation of the diagnosis."  Assumption coding is a forbidden practice among coders.

In other words, assumption coding occurs when the coder "assumes" certain facts about a patient’s condition although the physician has not specifically documented the level of detail that the coder is coding.

An example of assumption coding would be when a patient is admitted with pneumonia and the physician documents the condition as "pneumonia." The coder notes that a C&S was performed that revealed some gram negative rods in the culture. And, the patient is chronically ill and immunocompromized – conditions commonly found in patients with gram negative pneumonia. In this case, the coder would be engaging in assumption coding if s/he coded the patient’s pneumonia as gram negative pneumonia – in the absence of clear cut documentation from the physician that the patient’s case was gram negative pneumonia.

Coders can avoid assumption coding traps by using the physician query process, described below.