Problem: The record doesn't contain a legible signature and/or credential
Solution: If you hand write your charts, make sure your name and credential are on your progress note letterhead. If there's more than one person in the practice, have a check box (be sure to check it!) next to each name/credential.
Problem: The status of a disease is unclear, due to use of "history of"
Solution: Be sure to re-state any disease being assessed/treated on this date of service in the present tense, in your assessment. Be sure to include the patient's current status. For example, you might note "diabetes well controlled on diet, ck HbA1C 1 week prior to next visit. f/u 3 mos.
Problem: The documentation doesn't match the ICD-10-CM diagnosis code chosen.
Solution: This one comes in many flavors. Some of the most common are things like "h/o CVA 2-20-13, no neurologic deficits" and the diagnosis code is for an acute CVA. Another common issue is with amputations--the patient lost an arm in an accident 10 years ago, and the ICD10 code chosen is for a traumatic amputation. The last section of the ICD-10 is Factors influencing health status and contact with health services (Z00-Z99), and this section contains codes representing statuses like amputations and history of many illnesses.
Problem: The status of a patient's cancer isn't clear.
Solution: If the patient is still undergoing treatment, then it is considered an active malignancy. The ICD-10-CM, Chapter 2 m. "When a primary malignancy has been excised but further treatment,
such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to
that site, the primary malignancy code should be used until treatment is completed.
When a primary malignancy has been previously excised or eradicated from its site, there is no
further treatment (of the malignancy) directed to that site, and there is no evidence of any
existing primary malignancy, a code from category Z85, Personal history of malignant
neoplasm, should be used to indicate the former site of the malignancy."
Problem: The documentation is not sufficient to support a diabetic complication.
Solution: Be sure to document the history, physical exam and treatment directed at the complication.
Problem: Chronic conditions are not documented in the medical record at least annually.
Solution: This one happens a lot--and we often see signs (for example, medications ordered) that the disease exists. But unless you're documenting the disease, it's current status, and anything you've advised the patient, it can't be coded.
Problem: Electronic medical record is not signed.
Solution: Assign someone the task of following up on all records that have not been properly closed by authentication every week. Be sure that all staff are aware that they must close records by authentication immediately following the visit.
Problem: Diseases are coded without proper supporting documentation.
Solution: According to the Official Guidelines for Coding and Reporting, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, J.: "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management." If there's no documentation that they required (and received) treatment or management, or had an impact on your treatment of another condition, they should not be reported.
Problem: The diagnosis code chosen was more specific than the documentation.
Solution: Be sure you thoroughly document all illnesses, including their complications. Always document the patient's response (or lack of response) to treatment.
Problem: The diagnosis code chosen was not at the highest level of specificity documented.
Solution: This is the opposite of the problem above--you've documented the patient's condition and complications well--but chosen a code that doesn't reflect those complications. If the patient has multiple complications of a disease, each one should be coded separately.