Doctor, Documentation Really Does Matter

Documentation should paint a picture of the patient’s condition. Medical necessity drives every patient encounter. In fact, the Comprehensive Error Rate Testing Program (CERT) states that “medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” Diagnosis coding is very important for any specialty, and coding should be performed at the highest level of specificity. Coding and documentation should tell the payor what us going on, and why. Evidence in the documentation should identify clearly what services were performed and the reasons.

Time and time again, the industry has been telling physicians that documentation matters. If you think about it, patient care begins and ends with the physician in every setting. The physician or non-physician practitioner’s documentation drives everything. What I am seeing when reviewing physician documentation is lack of specificity and too many unnecessary unspecified codes being reported.

Lately I have been noticing some commonalities among physician practices large and small affecting documentation and reporting diagnoses with ICD-10.

The electronic health record (EHR) can be help or a hindrance when selecting a diagnosis code. For one practice I visited, when they typed in the diagnosis of “thrombosis,” all the available diagnoses were presented as a pick list, with the unspecified code listed first. Guess which one the physician typically selects? Of course, it’s the unspecified diagnosis. If you are using your EHR to select your diagnosis, make sure you build smart phrases or keywords to help narrow down the selection to a more specific diagnosis. If you have not built keywords or phrases, now is the time to start. 

Let’s review some common ICD-10 coding errors that merit attention:

Example 1: A surgeon documents in his operative report that the post-operative diagnosis is cystocele (N81.10). ICD-10-CM N81.10 is an unspecified diagnosis code, and based on the operative report, it is the correct code. But is it really? If the physician documented a midline, lateral, or complete cystocele, the ICD-10 diagnosis code could be more specific. Lack of specificity could trigger a payor audit.

Example 2: An ophthalmologist sees a patient with a chief complaint of “reduced vision getting worse.” The physician evaluates the patient and documents that the patient has an age-related sclerotic nuclear cataract of the right eye, reporting H25.9 (unspecified age-related cataract) on the claim, which is an unspecified code. The correct category is H25.1 for an age-related nuclear cataract. ICD-10-CM H25.11 (age-related nuclear cataract, right eye) is the appropriate diagnosis code for this patient encounter based on the documentation. Because the physician used a pick list to select the diagnosis code, H25.9 was listed first, which made it the most popular choice.

ICD-10-CM guidelines state that “codes titled ‘unspecified’ are for use when the information in the medical record is insufficient to assign a more specific code.”

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.

Another issue that comes up frequently is that if the physician is not managing a co-morbid condition, they do not report a comorbid diagnosis. Why not? For example, if a physician is treating a patient for pathological fracture of the hip, doesn’t the patient’s type 2 diabetes mellitus affect healing, or how the physician treats the patient? No matter what specialty, there are certain co-morbid conditions that do affect management of the patient’s care, and they should be reported as additional diagnoses.

By reporting the co-morbid conditions that affect patient management, it helps to ensure that the services provided are supported by medical necessity. However, the conditions must be documented in the medical record. If not documented, then the conditions cannot be reported. Remember, documentation should connect the dots between the condition (disease) and patient care.

ICD-10-CM guidelines also instruct us to “code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

ICD-10-CM can accommodate more specificity when describing acute, subacute, and chronic conditions. Documentation of the reason for providing the critical care service should be the principal/first-listed diagnosis, followed by any co-morbidities that affect management of the patient’s care. So many times physicians only report the condition he or she is managing, but that does not always provide a true picture of the patient’s condition.

Here is a good example of documentation that paints a clear picture:

This is a 55-year-old male with longstanding, insulin-dependent type 1 diabetes. Patient has been critical for the past three days. The patient presented in diabetic ketoacidosis and severe sepsis with septic shock due to acute pyelonephritis. He has developed acute kidney failure with medullary necrosis likely due to a combination of his compromised baseline renal function; baseline Cr is 1.8. Skin examination has revealed the presence of a grade 4 sacral decubitus ulcer, which was present on admission and is being managed by plastics. Patient has been intubated and on a ventilator for five days (Spo2 73 percent on 100-percent non-rebreather mask with respiratory rate of 28). Blood cultures positive for staph aureus sepsis. I am going to continue treatment with intravenous ciprofloxacin and vancomycin. Ongoing consultation with plastics for decubitus, as well as use of Roto-bed.

Is there specificity in the documentation? Yes. Striving for detail in the documentation not only allows the practitioner or coder to code specifically, but provides a complete picture of the patient’s condition. Even though another practitioner is managing the pressure ulcer, it should be reported, as it does affect management of the patient’s care.

Here is how the diagnoses would be reported:

E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
N10 Acute pyelonephritis
A41.01 Sepsis due to methicillin-susceptible Staphylococcus aureus
R65.21 Severe sepsis with septic shock
N17.2 Acute kidney failure with medullary necrosis
L89.154 Pressure ulcer of sacral region, stage 4 (present on admission)

The problem list can be problematic as well. Problem lists should contain items including acute and chronic issues currently managed by the practitioner, along with co-morbidities that affect management of the patient’s care. However, many times we see a laundry list of problems that no longer exist or have been resolved. Past medical history does not belong in the problem list.

The problem list is typically one of the last items in the medical record that is cleaned up. Actually, the problem list should be reviewed each time the patient is seen by the practitioner and revised during the encounter. Continuing to consistently bring in the problem list that is outdated each time the patient is seen creates a quality-of-care issue as well as a high probability for coding errors. 

The same can be said for the past medical history. The past medical history should include just that, not current problems. This should be routinely cleaned up as well.

Key Points to Remember:

• Clean up your EHR. If you are using a pick list, create shortcuts or key terms to narrow down choices for specificity.
• If the unspecified code is listed first in your pick list, move the unspecified code to the last position.
• Continue to use unspecified diagnosis codes when specificity of the condition cannot be determined. Each healthcare encounter should be coded to the level of certainty known for that encounter.
• Co-morbid conditions impact your resources and should be reported as additional diagnoses. Make sure they are documented.
• If the practitioner’s documentation is not clear or there is a consistent use of unspecified codes, query the practitioner for clarity.
• Clean up your problem list by keeping acute and chronic problems managed, as well as co-morbidities that affect management of the patient.
• Paint a clear picture in the documentation of the patient’s condition.
• Document and code to the highest level of specificity.
• The diagnosis code reported must be supported by documentation in the medical record.

It is just a matter of time before carriers audit your records for lack of specificity. Run a frequency report and perform a review of documentation for the most commonly used unspecified ICD-10-CM codes. 

If the documentation or the coding is insufficient, begin the process of documentation improvement immediately.