Is incomplete documentation affecting reimbursement for your practice?

Is incomplete documentation affecting reimbursement for your practice? As a physician or provider, your first priority is giving good patient care. However, you are still in control of how financial revenue is generated on a daily basis.

Since you are the integral piece of this financial venture, you should be aware of whether your charges are being paid, or denied. Many provider have a lack of understanding regarding why claims are denied. Unfortunately, the success of your practice or service may hinge on the success or failure of this revenue process.

According to the Texas Medical Associations’ Medicare contractor Trailblazer, the following E&M codes are the most problematic for getting claims paid correctly.
• New patient office or other outpatient visits - CPT codes 99201-99205
• Established patient office or other outpatient visits - CPT codes 99211-99215
• Initial hospital care for new or established patient - CPT codes 99221-99223
• Subsequent hospital care - CPT codes 99231-99233
• Emergency department services - CPT codes 99281-99285

The primary issue with the above listed codes, are these codes are the nuts and bolts of what we bill. The most common issue found with these codes is documentation by the providers. Incomplete or insufficient documentation leads to denials or take-backs of payment pending pre-payment or post-payment audits. Even if you feel you are documenting correctly, take the time to find out if your E&M codes are being denied.

The list below (also from the Texas Medical Association and Trailblazer) drill down to the most common ‘type’ of documentation errors they are discovering.
• Documentation does not support the level of service billed (i.e., up-coding or down-coding of services).
• Required components (as required by the CPT book) are not documented in the medical record.
o This includes the components of; history, exam, medical decision making and/or time.
o The history component is incomplete or absent.
o The medical decision-making documented is inappropriate or incomplete. Services were rendered by one physician and billed by another.
  • Documentation does not support a face-to-face encounter between physician and patient.
• The medical record contains conflicting information o the diagnosis on the claim is inconsistent with the diagnosis in the medical record o documentation in the patient's history conflicts with the examination o the date of service in the documentation is different from the date of service billed)
o The service is not performed on the date of service billed
o The service is/was not documented on the date of the visit.
• Medical documentation does not support medical necessity for the frequency of the visit

The big take-away from the above information, is as a provider, you are giving good patient care, but documentation of that care is a critical piece of our fiscal solvency puzzle. One of the ways to ensure that your documentation is up to scrutiny, is to ask and receive feedback from your coding and financial teams in regard to the denials that your practice is receiving. Analyze and educate yourself and your team for improvement. If you are struggling with the core concepts of coding, ask for help and/or education. The cost of the education is minimal, when compared to not receiving full reimbursement for the services you are providing. It costs far more to have claims denied, and appealed, than if they are correct the first time through.


In an OB/GYN hospitalist, or even a private OB/GYN practice, the “labor check” patients are thoroughly evaluated, and this should be substantiated by the diagnosis driver. If you are seeing the patient on the labor unit, or in the emergency department, this should not be considered a “normal” visit. It would be inappropriate to code these encounters with the V22.1 Supervision of other normal pregnancy code.

These visits should be documented with a clear diagnosis driver of an antepartum complication to the pregnancy. The use of code 646.83 Other specified complication, antepartum is a great code to use if there is not a code that fits the case your are working on. Use code 646.83 first, then specify what the reason for the visit is. You know what the reason is for seeing the patient, it just happens that you may have forgotten to get it documented, or documented clearly in the record.

The patients' presenting symptoms should be paramount in the first few lines of your documentation. One of the first things an auditor looks at is the chief complaint. The chief complaint should be very short, clear and concise. (eg. Patient thinks she may have leaking fluid, patient is having right sided pain and nausea; patient has had diarrhea and vomiting, etc..)

Ensure that the date the patient is seen, is correct in your documentation. The patient may have been admitted at 11:53 pm on 08/2/2013 to the labor deck, but if you did not see and evaluate the patient until 2:00 a.m on 08/03/2013, the date of service needs to be reflected as such. If the claim is denied, and has to be corrected – you may be required to amend the documentation, in addition to filing a formal appeal for re-submission.

Even if it only takes a few minutes for you to amend the documentation, the cost of doing business has just increased. These “quick” corrections still take your valuable time, that could have been better spent taking care of patients. In addition, this also costs the practice for the coder/biller’s time to gather your amended document, then re-send the claim for payment.

In some practices the physicians are coding their own claims, in other practices a coder oversee’s the charge entry process. In either circumstance, the provider or the coder should be reviewing the codes to the documentation on a regular basis. For clearer documentation and understanding of the claims processes, communicate with your coder, biller and practice manager on a regular basis to find out where your denials are, and if you can be an active part of reducing them. Happy Coding!