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The Documentation Challenge
Do You Pass the Test?

Throughout my 10 years of work at Texas Medical Association and my 10 years now as a practice management consultant, I have seen doctors become more involved in the business side of medicine. Doctors are becoming more aware of billing, coding, reimbursement, insurance contracts, staffing, workflow, budgeting, finances, and other areas that had not been followed by most physicians in the past. Despite this trend, many doctors are still unsure how to become more involved in their practice.

Many factors are pushing doctors to increase their awareness of the business side of the practice. Managed care and governmental agencies are demanding more doctor involvement as the number of whistle-blower lawsuits and fraud-and-abuse investigations is on the climb. Insurance companies are performing more documentation reviews, as physicians find their practices are exposed to a growing list of compliance issues. Although this involvement is not what doctors prefer, it can help a practice maximize compliance and revenue production as well as help physicians learn more about how their practice can operate efficiently.

One area that physicians find extremely frustrating is documentation. Most doctors will admit that medical school did little to prepare them for how to document their services correctly. Yet it has become increasingly important to document appropriately to protect the practice from potential audits and refunds for incorrect documentation. I would estimate that more than half of physicians reading this article are not documenting accurately for code level. I perform many reviews and see this consistently among doctors of all specialties.

Almost 40 percent of Medicare payments are made for evaluation and management services. These office visit services are the bread and butter of primary care, so the exposure is high. I recently spoke with a doctor who had received a letter from Medicare addressing the possibility of incorrect documentation. The letter requested records to substantiate the codes billed. The practice submitted the information and after a few weeks got a refund request for a large sum of money. They are currently working with their attorney, but their experience shows why physicians have to do a better job with their coding and documentation.

I got a call from an attorney about a report I wrote for a practice that described a problem with the billing of a physician assistant the practice employed. The rules for billing PA services require a modifier and reduced payment by some insurance plans. The practice was not consistently complying with these rules. The decision was to conduct an audit to determine how much exposure the practice had, and then contact Medicare to work out repayment if necessary. This practice could have avoided an arduous audit had they initially established systems to identify such problems before they became nightmares. We have to do a better job in our coding and documentation.

Medicare has set a precedent that others have followed. Random and outlier audits are being conducted more than ever. Recovery Audit Contractors are reviewing records routinely and collecting money back when overpayments are found. These companies are paid a percentage of what they recover, so the incentive to identify inappropriate payments is strong. Insurance plans have sophisticated tools to measure how a doctor is doing and request documentation when it appears he or she may not be documenting correctly.

Document using one of two guidelines

The Centers for Medicare and Medicaid Services in conjunction with the American Medical Association developed guidelines to help physicians document evaluation and management—or E/M—services, which include office visits, hospital visits, and consultations. There are two versions of these guidelines. The first set was developed in 1995 and a more recent version was completed in 1997. These can be found by going to the Trailblazer website at www.trailblazerhealth.com. Physicians may use either version based on their preference. The difference is in the examination; the 1997 version is based more on body areas and organ systems, whereas the 1995 guides are based on multi-system exams typically provided by primary care physicians. The problem with these guidelines is that in some cases, they are difficult to interpret.

Regardless which version you choose, ensure these guidelines are followed and that you are documenting appropriately. In audits I conduct, I typically use the 1995 guidelines because Medicare indicated that they will use either guideline, whichever is better for the physician. What Medicare found, and subsequently I found in my reviews, is the 1995 guidelines allow the doctor to reach some of the higher levels more consistently that the 1997 guidelines.

Be Legible

Doctors are notorious for writing notes in the chart that can only be interpreted by the doctor who wrote them or a handwriting expert from CSI: NY. Sometimes the doctor can’t even read what he wrote. A recent article published by Medicare stresses the importance of legible records and a legible identity of the person doing the exam. I see records that can be read, but the signature of the person who provided the service is not legible. This needs to be as clear as the information presented. The government will not be lenient if they cannot read the documentation, and they may require a full refund. Anyone who has gone through an audit has been told that if it is in the record and can’t be read, it did not happen. Each date of service has to stand alone. A reviewer is not going to go back in the record and try to figure out what you did that day.

Chief Complaint

A chief complaint has to be documented at every encounter. Many of the records I review have the words “follow-up.” That’s not going to cut it. The record needs to clearly define what the follow-up is for to get credit for the chief complaint. Follow-up for diabetes, hypertension, headache, etc., more clearly indicates why the patient is being seen than just “follow- up.”

Review of Systems

Many doctors do a limited review of systems. A review of systems is mandatory for coding some of the higher-level services. Many doctors don’t realize that a review of systems recorded in an earlier encounter does not have to be re-recorded if the notes indicate the date and location of the earlier review. This is also true for the past, family, and social history. Higher-level codes such as 99214 and 99215 require a more thorough review of systems. I realize that doctors are doing a review of systems, but it is either not being documented or is limited. Level-four new-patient visits and level-five established visits require 10 items documented from the review of systems. Keep this in mind for accurate coding.

Medical Decision Making

Remember that medical decision making is made up of the number of diagnoses and management options, the complexity of data to review, and the risk of complications. Each of these has to be considered in the code choice. This area is more subjective and care should be taken when determining the medical decision making for any level. Recently, more information has surfaced about medical decision making and specifically medical necessity. A recent article published by Medicare stated that the definition of medical necessity requires that paid services meet but not exceed the patient’s medical needs and be provided in accordance with accepted standards of medical practice.
Accordingly, Medicare believes that the patient’s condition (e.g., severity, acuity, number of medical problems) is the key determinant for the frequency and intensity of E/M services for which Medicare pays. Coding E/M services first on the basis of medical necessity followed by verification of documentation of required key work components for the selected code allows clinicians to avoid several common pitfalls of E/M documentation and coding. In other words, don’t forget about the importance of medical necessity in the ultimate decision of code choice. There are electronic medical record systems that assist doctors in choosing the correct code. Sometimes the system may recommend a higher level code even though the medical necessity is not extensive to warrant the code. A comprehensive history and examination may not be appropriate when an established patient is seen for sinusitis. Make sure discretion is used when choosing the code.


Time is a controlling factor in code choice when more than half of your visit is spent in counseling or coordination of care. CPT defines the E/M codes by typical time. If the doctor spent over 50 percent of his or her typical time counseling, then choose the code based on total time. For example, an established patient is seen for depression and the physician spends 40 minutes with the patient. Thirty of the 40 minutes was spent counseling about the problem and options for treatment. Since 50 percent of the total time was spent counseling, the code chosen should be based on time. In this case CPT 99215 should be billed because the typical time is 40 minutes. Make sure you document the time in your notes, “a total of 40 minutes was spent with the patient, the majority of which was in counseling.” This will allow you to code appropriately.


Primary care physicians don’t typically bill consultations. However, you can use these for pre-op clearance for surgery requested by a surgeon. Consultations have to be used when your opinion or advice is given and you must send a letter back to the referring physician. As of Jan. 1, consultations have been removed from payment for Medicare services. Nevertheless, these codes can still be used for other payers including Medicaid.

Understanding documentation can have a huge impact on your bottom line. It can be confusing and complex until you are very familiar with the guidelines. Don’t fall into the trap of down-coding your services if you provided the work. Sometimes it is beneficial for a practice to have a documentation review to determine opportunities for improvement.

By Bradley K. Reiner
Practice Management Consultant, Reiner Consulting and Associates

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