Auditing Issues Uncovered in Physician Documentation: Part II

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor

Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI.

Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor.

Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I

As I discussed in the first portion of our series on physician documentation issues during an audit, errors can occur on both sides, physician documentation and coding – even with proactive clinical documentation improvement (CDI) departments correcting negative behaviors and coders trying to educate physicians and mid-level providers on what is needed to support a particular level of service.

But it is an ongoing process. Physicians and physician-extenders alike get busy and overwhelmed treating patients, with their ever-increasing volumes, and even with the assistance of the electronic health record (EHR), deficiencies will happen. Some of the good documentation and coding behavior upon which physicians were educated and trained on tends to fall by the wayside over time. In my experience, there is marked improvement within the first three to six months after training sessions, and then a decline in accurate documentation starts to show. Many records start to feel like they were rushed, or only slightly edited, and not actually taken during the patient encounter.

Article originally published on May 8, 2018 by ICD10 Monitor.