Strong documentation is the key to effective coding. Without accurate clinical notes, compliance risks increase and reimbursements are reduced. ReveNews recently spoke with McKesson certified coders about common documentation errors in emergency medicine.

When it comes to emergency medicine, clinical documentation can sometimes be overlooked amid the scramble to assess, triage and stabilize patients, according to Kathryn Davis, CPC, CPC-H, CEDC, a certified emergency department coder and physician documentation educator with McKesson Business Performance Services (McKesson).

“Emergency physicians are very dedicated and focused solely on taking care of the patient,” she said. “So that means they often don’t realize that the specific services they’re providing should be fully documented for appropriate reimbursement.”

Critical Care Time

One of the most common problems in emergency medicine involves physicians’ failure to document critical care time. As defined by the Centers for Medicare & Medicaid Services (CMS), critical care time includes all activities relating to the care and stabilization of a patient with a life-threatening illness or injury.

For physicians, that can mean everything from bedside assessments, charting completion, monitoring vitals and reviewing all ancillaries (labs, x-rays, EKGs, cardiac monitors), to discussing care with the patient, family members and/or other providers.

“The best way to explain critical care time is that it involves everything you do for a patient who you see immediately upon presentation, and who you’re worried about through their entire visit,” Davis said.

By failing to designate critical care time, physicians are leaving money on the table, Davis said. The amount ultimately depends on the payer and applicable discounts, but billable charges associated with critical care time frequently can range from $300 to $600 per encounter per geographic location, she said.

Some emergency departments employ scribes, or individuals charged solely with reviewing and documenting the physician’s activities. These professionals can play an important role in prompting the provider to record critical care time, she said.

Organ System Documentation

Another problem that Davis frequently encounters in emergency medicine is the failure by physicians to adequately document the review of organ systems (ROS) during the initial subjective patient assessment.

In order to receive the highest level non-critical care code, physicians must review 10 or more organ systems to determine any positive or negative correlation with the patient’s presenting problem. Too often, Davis said, physicians will document only a handful of organ systems, even if their medical decision-making process involved questioning the patient or otherwise assessing additional systems. The inability to code to highest-non-critical code can result in lost billable charges of between $100 and $300 per encounter per geographic location, Davis said.

Beware of Audits

Beyond helping ensure appropriate reimbursement, accurate and detailed documentation is necessary to minimize the risk of a payer audit. Davis noted that contractors employed on behalf of government and commercial payers can be extremely aggressive in their pursuit of alleged or apparent fraud, errors, waste and abuse.

“One of your objectives as a physician should be to keep the auditors away from your organization,” Davis said. “And the way you do that is with accurate documentation. Because you really don’t need the kinds of problems they can create.”

As important as documentation accuracy is in today’s environment, detailed and precise clinical notes will become even more essential once the ICD-10 code sets take effect in October of this year, Davis added. ICD-10 documentation requires considerably more clinical and anatomical specificity than the current ICD-9 system.

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About the author

Robert Bunting, CPC, CPC-H, CHC, CEDC, CEMC, CAC is Compliance Director – Emergency Medicine, McKesson Business Performance Services.