EyeNet Magazine

Practice Perfect: Compliance & Risk Management
Chart Smarts: Benefit From Better Documentation
By Chris McDonagh, Associate Editor

How would your chart documentation fare in an audit? “With the frequency of audits from all payers, it is not a question of whether an audit occurs but when,” said the Academy’s coding executive Sue Vicchrilli, COT, OCS. “While nobody goes to medical school because they want to learn what documentation payers require, the reality is that when a third party is paying the bill and you’ve agreed to be a participating physician, the payer does have input.” And the bottom line is that if it isn’t documented, it may as well have never happened.

To ensure that you are reimbursed appropriately, your charts must fully substantiate the chief complaint, the medical history of your patients, the elements of the exam and the medical decision-making to determine overall risk. The chart itself should be clear, accurate and complete, and the claims that you send to payers should reflect exactly what’s in that chart.

This required documentation should begin even before the patient gets to the office. Is your receptionist trained to document missed/failed appointments, cancellations and any unusual concerns that patients may voice over the phone?

Forms, Lists and Norms
Make sure your practice has the tools that it needs to support good documentation. Do you, for instance, have a history form that is compliant with E&M requirements, as well as state- or payer-specific requirements?

These tools should include a list of abbreviations and, if you’re in a large practice, signatures of all the technicians and physicians, said Gaye A. Baker, OCS, a member of the AAOE board of directors and a reimbursement specialist at the Mason Eye Institute at the University of Missouri, Columbia. “If auditors ask to review the charts, you can tell them, ‘Here’s a list of the abbreviations that we use and here’s how we sign the charts,’” she said.

And suppose your practice decides that the Dictionary of Eye Terminology’s list of abbreviations and acronyms will be your touchstone, are you checking that everybody is on the same page?

Chart Essentials
Clarity. Each page should have the patient’s name and chart number and all entries must be legible enough so that anyone outside your practice can understand what occurred at a visit. “If auditors are unable to read the writing, they may decide to either request a dictated report, perform an audit based on what they can decipher or deny the claim entirely,” said Ms. Vicchrilli.

Accuracy. Make sure that your chart tells the entire story of the patient encounter with regards to what happened, how and why. “But don’t include any opinions or derogatory remarks in the chart that you wouldn’t want somebody else to see at a later date,” said Ms. Baker.

Corrections. “Only the person who wrote the incorrect entry can correct it,” said Ms. Baker. “He or she would do so by drawing a single line through it (so the underlying text is still legible), and dating and initialing the correction. If you notice something wrong in the chart that somebody else entered, you can’t correct it—you would have to make an additional entry. All late entries must be dated and filed chronologically.”

Confidentiality. Any request for medical records must be done in writing. “Suppose, for instance, another medical office phones your office asking you to fax a patient’s chart notes. You should refuse to do so until they send you notification signed by the patient indicating that they want the records released,” said Ms. Baker.

History in the Making
“Details from audits show us that approximately 80 percent of downcoded visits are downcoded because of inadequate history taking,” said Ms. Baker. The patient’s history ought to include the chief complaint, a history of the present illness, a review of systems and past family social history. To ensure history is on your side, avoid these mistakes:

Never describe an exam as “routine,” said Ms. Baker. “Tell technicians that you don’t want that word in their vocabulary when it comes to your medical records. Explain to them that very few insurance companies will pay for a routine visit, and when auditors see the word ‘routine,’ they won’t look any further into the chart.”

Don’t just document, “Patient here for three-month follow-up.” You need to explain what the follow-up is for, said Ms. Baker. And if it is an off-cycle visit —suppose you normally see a patient every four months for their glaucoma, and they now have an issue that is unrelated to that—then you would document it as a new encounter, indicating that the patient’s complaint is separate from the ongoing condition.

Don’t forget to document functional impairment. For instance, a patient’s vision may be better than 20/50, which is what Medicare requires in many states to qualify for cataract surgery, said Ms. Baker. But if the patient can’t drive at night because of glare, that may provide the medical necessity that you need.

In your review of systems, don’t fall into the habit of always using the same two or three signs, warned Ms. Baker. “If an auditor sees ‘No chest pain’ and ‘No shortness of breath’ on each chart, he or she may assume that you’re not really doing the review of systems.”

When documenting the patient’s past family and social history, don’t forget to include the date of any past injuries, illnesses or treatments. If patients are in the postop period, that date will help you code the visit.

Submit Claims Correctly
The documentation may be an accurate reflection of the service that was provided, but is that accurately reflected in your practice’s claims form?

“There should be a straight transfer of data to the claims form,” said Ms. Baker. “But often when you get talking to the billing office, you find that some assumptions were made. For instance, a biller might tell you, ‘The doctor wrote cataract, but we know she means nuclear sclerosis—so we’re going to pick that code.’ Or,‘The doctor said come back in six months for an exam, but we know she wants a visual field as well, so we’re going to add that test.’”

In other cases, you may find that a physician or biller takes a conservative approach to the claims form: “I don’t really understand what’s needed for that Level 4 exam, so I’m going to be safe and go for a Level 3.” With just a little training, you can code correctly for the higher code when the medical necessity is there, said Ms. Baker.


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