by Taylor King, CPC, RHIT
It’s no secret that the topic of clinical documentation has been in the hot seat lately. Has the importance of documentation been far exceeded by the importance of speed? Are providers in a hurry to rush one patient out only to scurry on to the next? While we don’t have all the answers, there are a few clinical documentation issues that have stuck with me. I have seen these errors across various hospitals, providers, and specialties, and there is no trend that I can see.
Missing Laterality
How can laterality be such an oversight while documenting the patient’s condition? Is it carelessness or something else? I’ve seen Oncologists fail to document the laterality of breast cancer. Is this real? I must have been having a nightmare! It’s imperative that laterality be documented, not only for the integrity and continuity of the documentation, but for coding and reimbursement purposes. Unless there is a need for an unspecified code, most insurance carriers will deny claims with unspecified codes. If the code is truly unspecified and the carrier denies the claim, you can appeal with documentation if necessary. Section B.13 of the ICD-10-CM Guidelines for 2023 state, “Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.” (Center of Medicare and Medicaid Services, 2022). If available, laterality is allowed to be pulled from documentation that was done by someone other than the physician themselves. This could be a medical assistant, nurse, or another healthcare professional.
Addressing a Diagnosis Without Exam Documentation
We’ve all seen it. Let me paint you a picture. Johnny comes into the office with a chief complaint of right sided ear pain. The HPI includes an appropriate excerpt on the patient’s condition. The provider documents the exam of the right ear canal and positivity for ear pain, finding impacted wax. Moving along, the assessment and plan states impacted wax of the right ear and a rash on the right forearm. The documentation does not state anything about a rash, and the patient did not present this as a complaint.
The American Medical Association (AMA), along with many well-known auditors that I’ve known, have stated that there should be a "…medically appropriate history and/or exam performed" (American Medical Association, 2019). If the note does not state anything about the rash anywhere, then how can you justify diagnosing and documenting the rash in the A/P? Simple. You can’t.
Allergies, Medications, and Conditions
Failure to accurately document a patient’s allergies, medications, or conditions can occur from the medical assistant, nurse, physician, or other healthcare professional. Errors of this magnitude can, at best, be caught when reviewing with the patient, or at worst, be fatal. I'll give you a real example with my own condition. I have Celiac Disease, which is an autoimmune disease that is reactive to gluten from wheat, barley, and/or rye. If this information were left out of my chart, I would be at risk of unknowingly consuming medications or hospital food with gluten. If this were to happen, my body would begin feeling side effects within 20-30 minutes. My symptoms include palpitations, clammy hands, dizziness, blurred vision, migraines, intense brain fog and memory issues. All of this could occur if even one person were to not accurately document my condition. In more severe cases, patients could have mixed medications causing a reaction or fatality.
I’m not a physician educator, so I can’t speak to the level of documentation education that physicians or other healthcare professionals receive. However, I’d like to see a stronger push for accurate clinical documentation overall. This should be Healthcare 101. As a medical coder, I see documentation errors daily, as well as carrier denials for unspecified codes that were sent on the claim straight out of the offices. What if it was YOU on the other side of the clinical documentation error? Would you be happy with our current state of clinical documentation standards?
Citations:
American Medical Association: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
Center of Medicare and Medicaid Services. (2022, October 1). ICD-10-CM Guidelines April 1, 2023, FY23. Retrieved from CMS.gov: https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf
About the Author
Taylor King, CPC, RHIT, is a Pro-Fee Edits & Denials Specialist with YES-HIM Consulting, Inc. She has been coding for 2.5 years, with a primary focus on claim denials. Taylor attended Marion Technical College, where she obtained her Associate's Degree in Health Information Technology. She is also the Vice President of AAPC's Mansfield, Ohio Chapter. In her free time, she enjoys spending time with her three children, shopping, and mentoring new HIM professionals.
