Q & A Corner

Avoid denials for similar’ visit documentation

By Linda Howrey, CPC, CCS-P
Coding Consultant
Howrey & Associates
Jefferson, MA

Q: A recent Medicare bulletin states that if visit documentation for a patient "looks similar" from visit to visit, Medicare will deny payment for the visits due to lack of medical necessity. What does "similar to" mean?

A: Looking "similar" means that the physician didn’t dictate a new note for each visit. This can be a problem when an electronic medical record (EMR) pulls all the information for each encounter into the next one.

It’s not known if the physician actually looks at the information or if the EMR is simply printingit out into the progress note. As a result, every visit looks alike.

Ensuring visit took place

The Health Care Financing Administration’s concern is that the work isn’t being done; the provider is just adding the information with a few flashy clicks of a button, making the work look like a Level 5 service when the provider has not done the work associated with that level of service. The carrier is looking for something that indicates progression, improvement, or something that shows what is really happening with the patient at the time of the most current visit.

Documentation guidelines for the progress note say that the history should be based on the last encounter. Providers need to update that medical history from the last patient visit and not just repeat history information that is not relevant to today’s visit. Some providers bring back complete patient histories every time the patient comes in.

Physicians, therefore, need to make sure that their history is unique to that day’s visit. They also need to reference anything that is key to treating the patient during the visit.