One of the hospitalist groups I work for has a coding specialist that examines our charts to make sure we are following the coding rules. They read through our notes and compare them to what we coded.
Here are the things that I have gotten dinged on:
- Not putting the family history. Sometimes it doesn’t apply (like in a 90 year old!) but according to the consultant I should list it any way. Well, okay, easy enough.
- Forgetting to put my total time. (Duh. Sometimes I’m just an absent minded professor!)
- Forgetting to put who asked me consult and why. She reminded me that a consultant asking me manage a medical problem does NOT count as a consult, and that I couldn’t even bill and H&P–just another rounding code.
Ridiculous stuff the coding consultant said:
- She told me to spell out HEENT in my notes etc. She said this will soon be unacceptable.
- She told me I couldn’t put ROS after the HPI. To me this is the most logical place–usually the ROS is directly related to the HPI. I have taken the great step since residency of moving the ROS after the HPI. Sorry, but I ain’t changing!
Take away: put in the family history, document your time and remember who asked you to see the patient. Will improved coding make that much difference? We’ll see-I doubt I’ll get paid more, but maybe my chances of getting audited will go down.