Documenting and Coding Systems for Success

Successful providers review their documentation and coding and strive to improve accuracy and compliance. Documentation involves far more than just writing down a list of services or copying notes from visit to visit. Likewise, proper coding involves more than just figuring out what codes the payer will accept and billing those. These habits or documenting and coding systems can make or break your reimbursement as well as indicate your compliance risk. Create checklists and cheat sheets for each type of patient visit to help ensure that all the proper criteria are met and save the headache and cost of denials later.

Let’s begin with documentation!

Most patient visits fall into one of three categories: Initial Visit or New Episode, Periodic Reevaluation, and Routine Office Visits. Creating a checklist for each of these will help prompt you to provide all the critical elements required for relevant and compliant notes.

The following are some examples of what you should include when creating your checklists for documenting and coding systems.

Initial Visit or New Episode

As this is an Evaluation and Management (E/M) service and the foundation of the episode, your checklist should include the following:

• Patient history of each complaint…known as, History of the Present Illness
• Review of involved systems, like musculoskeletal and neurological, or any others that may be connected to the chief complaints
• As applicable, the patient’s:
  • Past History
  • Family History
  • Social History
• Exam Findings for each area of complaint
• Initial Assessment that includes prognostic and other complicating factors
• Diagnosis to include all areas you intend to treat
• Treatment Plan to include goals, both short and long-term, as well as frequency and duration of the proposed visits, and each recommended service with rationale

Periodic Reevaluation

Documenting the patient’s progress isn’t just important, it is required to support continual care. The steps for documenting a reevaluation may seem very similar to that of the initial visit but should also include recording details that allow for comparison with your initial findings so that you may demonstrate progress. When creating this checklist, add the following:

• Status of reported complaints
• Exam findings that demonstrate progress, or the lack thereof
• Updated assessment of patient condition and progress to include current goals and Outcome Assessment scores
• Diagnosis updates
• Treatment Plan revisions

Routine Visits

Routine visits document the execution of the treatment plan and must include specific elements to track patient progress from visit to visit. Use the following elements as the checklist for these types of encounters:

• The patient’s own assessment of their function
• Daily objective findings
• Provider commentary regarding patient improvement and the need to continue care
• Details of any treatment received

Next up, Coding!

All coding comes from documentation. ICD-10 coding requires precision to identify the condition recorded in the documentation that the provider intends to treat and affect. Therefore, it goes hand in hand with your documentation which must dictate and support the ICD-10 codes you choose. If your documentation is careless and not concise, it will cause you to utilize non-specific or unclassified codes that will quickly raise red flags for claims adjusters.

While not every ICD-10 code is site-specific, many are. It makes sense to keep a cheat sheet of spinal sites/regions diagnosis codes to reference when documenting. If you are uncertain about which ICD-10 code to utilize, you should be able to locate the answer within your documentation. If you cannot, it may indicate that your documentation needs improvement, and you should refer to the checklists referenced above. When your documentation is on point, the correct codes will be easily revealed.

Procedure coding hinges on correctly identifying the service being performed and the support for that service as noted in the documentation. It is of the utmost importance that every practice identifies each service with the accurate code. Creating a cheat sheet or routing slip to include the services available provides clarity for the entire team. Have a system in place to verify that the documentation supports the procedure codes assigned using the documentation checklists above.

By creating a few simple and effective tools, your documenting and coding systems will be on track and lead to success in no time!

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.