Essentials of a medical record

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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Have you or your patients noticed that at times the patient-physician interaction process seems to have been subjugated to the documentation proceedings, with interactive patient care appearing almost as an afterthought to the compulsive drive to thoroughly list all facets of the interaction? Some of this may be stimulated by the ingrained refrain of, “If it isn’t documented it wasn’t done,” and some from a pressure to satisfy evaluation and management (E/M) billing criteria for selecting an appropriate CPT code.

The Medicare Learning Network (MLN) November 2014 “Evaluation and Management Services Guide” posits that complete documentation is necessary for providing a patient with quality care. Although documentation is helpful to formulating care, it does not in and of itself provide care. Quality care results in happier patients with a reduced, controlled, or banished burden of disease achieved in a cost-effective fashion.

So, how and why is documentation necessary? Well, precise and complete recording of a patient’s state can help with comparative future assessments of the patient both by the same caretaker and by others, is essential to determining appropriate levels of E/M billing, and can be crucial to protecting (or harming) the medical professional in medicolegal situations. However, one should recognize that patient care is what the practice of medicine is all about. This concept seems to have been partially corrupted by those who push exhaustive electronic documentation, physician quality reporting, and other metrics that in various ways degrade the time for and quality of physician-patient human interactions.

So, what is essential to the medical record? Beyond describing the patient encounter and the diagnostic and treatment plan, the medical record determines the level of E/M billing and provides a justification for what you did. The record should also offer information that an insurer could effectively use to determine the medical necessity for a service, and extractable reasons for diagnostic and treatment actions. Keeping in mind that when not medically necessary or non-covered services are suspected by your Medicare contractor, and documentation to support medical necessity is lacking, payment for the service will be denied. Worse yet, if your Medicare contractor determines that a billed service was not medically necessary or is non-covered, and you had not obtained an Advance Beneficiary Notice (ABN) and indicated as such to Medicare with an appropriate GA, GX, or GY modifier (see sidebar), your services will not be paid and the patient will be notified that they are contractually absolved of any payment for the services. Clearly, there is a tight relationship between documentation and proper CPT coding.

The MLN Evaluation and Management Services Guide lists the following essential components of a medical record:

  • The medical record should be complete and legible.
  • The documentation of each patient encounter should include:

    o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results

    o Assessment, clinical impression, or diagnosis

    o Medical plan of care

    o Date and legible identity of the observer

  • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
  • Past and present diagnoses should be accessible to the treating and/or consulting physician.
  • Appropriate health risk factors should be identified.
  • The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
  • The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

What is not stated in the above guidelines is that the information gathered should serve the diagnostic and treatment plan, and should constitute medically necessary information. Material consistently re-listed verbatim from a prior encounter (cloned), and recorded data that is irrelevant to the patient’s current complaints and care, may not be counted by the insurer for determining a particular level of E/M CPT code. Cloning refers to a duplication of charted verbiage from visit to patient visit. There are instances, however, when the use of identical language is appropriate. Such may be when a described clinical presentation duplicates that of a previous visit, when elements of a surgical procedure are nearly identical from case to case, and when tissue histology is nearly the same in various specimens, such as nodular basal cell carcinomas.[pagebreak]

The growing dominance of electronic health records has engendered a rise in the levels of billed E/M codes. This trend has been facilitated by two factors: the tracking of legitimate recorded data has sometimes uncovered higher levels of service than were previously suspected and billed; the same tracking has also facilitated an accretion of irrelevant data gathering resulting in upcoding of E/M services. If the gathered data is not necessary for the patient’s care, then it may be disallowed by an insurer for the purposes of calculating a level of E/M service. Specifically, the Medicare Claims Processing Manual, Chapter 12, indicates the following: “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Example 1: A Medicare patient requests to have several seborrheic keratoses removed, as they are “unsightly,” and also mentions that one of them has been itching intensely, and has grown “overnight.” You document the symptoms and signs, and proceed to freeze the symptomatic keratosis along with 12 other keratoses with liquid nitrogen. You bill CPT 17110 for the destruction of the keratoses.

Answer: Correct. CPT code 17110 specifies the destruction of up to 14 benign lesions. It does not matter whether one or 14 were destroyed. The code is the same. In this case, the destruction of one documented inflamed seborrheic keratosis represents a legitimate covered service, and that justifies the billing, which would also, by definition of the 17110 code, include the destruction of the additional 12 keratoses, no matter whether that was done for cosmetic or medical reasons.

Example 2: Another Medicare patient also has a legitimately described and documented inflamed seborrheic keratosis. You freeze the offending keratosis with liquid nitrogen along with seventeen other asymptomatic keratoses that the patient desired off. You bill Medicare CPT 17111 for the destruction of 15 or more benign lesions.

Answer: Incorrect. The destruction of the one inflamed keratosis represents a legitimately covered service. The freezing of the other 17 lesions was done for cosmetic purposes. Consequently, although a total of 18 keratoses were frozen, only CPT code 17110, representing the destruction of the one covered entity, should have been submitted to the Medicare contractor for covered payment. Since more than 14 lesions were destroyed, one may choose to directly bill the patient with CPT code 17111 for the additional 17 keratoses destroyed for cosmetic reasons. Although Medicare does not need to be billed for the cosmetic destruction, if the patient were to insist upon a billing in order to receive payment from a secondary payer, it would be best to submit the 17110 billing with an appended GY modifier, indicating that the service is statutorily not covered by Medicare. (The GX modifier can also be reported if a voluntary ABN has been obtained. Learn more about appropriate use of ABN modifiers.

Example 3: You thoroughly evaluate an uncomplicated acne patient treated with topical medications, incorporating a complete skin examination, palpation of lymph nodes, and palpation of the thyroid during every encounter. Your electronic medical records system then uses all of the components of the physical examination in calculating the proper level of E/M service.

Answer: Incorrect. Although a rather extensive physical examination was done at every visit, one may legitimately question the medical necessity for doing a complete skin examination and palpation of nodal basins as well as of the thyroid at every visit, and integrating those into the calculation of the E/M service level.

Modifiers for Advanced Beneficiary Notices

GA: Indicates that a given charge may or may not be covered by Medicare, and that an ABN has been obtained and is on file.

GX: Indicates that a service is not covered because it is statutorily excluded from coverage or is not a Medicare benefit but an ABN has been obtained as a voluntary option.

GY: Indicates that the service provided is statutorily excluded from coverage. (Note that in such a case one is not required to submit any bill to Medicare).


Related Resources

Modifiers for Advanced Beneficiary Notices