DRG Coding Advisor-Making histories unique avoids similarity problems

Question: 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 "looks similar" mean?

Answer: Looking "similar" means the physician didn't dictate a new note for each visit. This can be a problem when an electronic medical record 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 system is simply printing out into the progress note. As a result, every visit looks alike.

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 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, or improvement, or at least what is really happening with the patient at the time of the most current visit.

Documentation guidelines for the progress note say 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 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.