Choosing words are very important in the medical field. The right words can mean the difference between accurate evaluation and management (E/M) coding or being accused of submitting false claims.
The words left behind in the medical record form the basis on which an auditor decides if the doctor provided appropriate care, or submitted an accurate claim, or committed the crime of submitting false claims. The auditor must examine the medical record documentation to recreate the intensity of the service.
Words convey meaning. What happens when the writer’s meaning is at odds with the reader’s interpretation? At best it results in confusion, at worst, potential allegations of wrongful code selection.
Trap #1 (Non-Contributory):
Most payer auditors disallow a history element or review of systems that is described as “non-contributory.” The rationale is that there is not sufficient information provided to adequately understand which questions the patient was asked regarding his/her history and/or review of systems. Physicians commonly tell us that they “meant” that the patient’s response was negative; therefore, they did not direct the evaluation in a specific direction.
If the patient responded in the negative, document “family history is negative for (whatever you asked about,)” or that, “the review of systems is negatively related to (state the systems asked about.)”
Trap #2 (Referring Physician):
Using referring physician when intending to communicate that a specific physician has requested a consultation service. “Referring” implies (to some) that the care of the patient is being relinquished to another physician.
Say that Dr. X requested a consultation to evaluate whatever the condition for which you are being consulted.
Trap #3 (Missing Words):
Thinking that severity is “obvious” and neglecting to use adjectives to describe a severe exacerbation, progression, or side effect of treatment related to a chronic illness being treated. These descriptors support medical necessity for higher levels of services than the same chronic illness that is stable or mildly progressing, a mild exacerbation or a mild side effect of treatment.
State the obvious. Use language that leaves no doubt about the severity of a condition for which service is being provided. Words such as “severe,” “crisis,” “at high risk,” “deteriorating” etc., convey information clearly and are not likely to be misinterpreted.
Trap #4 (Clinical Information):
Relying on clinical values and findings to communicate the severity of illness and complexity of care. Medical record auditors rely on adjectives for this information and are mostly not permitted to interpret clinical values.
Use words that describe what the clinical data communicates to you. For each established diagnosis, specify if the patient’s condition is stable, improved, worsening, etc.
Trap#5 (Chief Complaint):
Chief complaint: f/u. This common abbreviation for follow-up does not describe to the auditor what condition(s) is being followed up on.
State follow-up for, and insert the condition(s), including both those that are receiving active care and any comorbidities that affect the physician’s thought processes in providing that care.
Perhaps the biggest trap of all is thinking that only words drive the code. While it’s important to completely record the work done, doing it for the “sake of a code,” may not stand up to audit scrutiny.
Use the right word to accurately describe the patient’s visit (avoiding those known to cause confusion). When the words you choose are precise and include sufficient detail to paint a word picture of the visit, the auditor can reconstruct the episode of care to validate code selection(s).