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Good patient records benefit your practice, your staff, your patients
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Health care providers have long been known as independent thinkers, regardless of their mode of practice. Whether the doctor is in solo practice or whether he or she is a single cog in a huge health care delivery machine, the doctor is probably accustomed to a wide degree of independence.
Nowhere has this independence been more apparent over the years than in doctors’ patient records. There are thousands of variations of the standard record form available commercially and tens of thousands that are maximally individualized, where doctors simply record their findings on a blank sheet of paper. Any of these is just fine, providing the record fulfills its purposes.
Internal uses
Health care providers keep a record of what is done during a patient encounter for several reasons. The main reason, historically, has been to record what the patient says during an encounter, what the doctor and staff do with the patient during the encounter and what the doctor decides to do for the patient as a result of the encounter. This might be thought of as internal use of the chart. Until a decade or two ago, the information in the record was used only by the doctor and staff and was seldom seem by anyone else, not even the patient.
In those days, the record would be kept in the doctor’s files indefinitely, and it was relatively rare for a record to be used by anyone other than the doctor who originally wrote it. Even that caused problems sometimes, as doctors would use abbreviations or penmanship at one visit that would be indecipherable the next time the patient appeared at the office. New staff would often require months to become familiar with the “language” of a particular office, even if they had worked in a similar office previously.
External uses
These communication challenges are magnified any time the record is needed outside the office in which it was created. These might be thought of as external uses of the chart, meaning that the chart is transmitted to the patient, to a new doctor, to a health care insurer, to a governmental agency, to a district attorney and so forth. As these uses became more frequent, the problems with patient records became more apparent. The need for some standardization of form and language became more urgent in the health care system.
SOAP format
The SOAP (subjective, objective, assessment, plan) format provided a fairly innocuous first step. It was recognized that most patient records follow the pattern of having the patient interview or case history at the beginning of the record (subjective), the examination findings in the middle of the record (objective) and the decision-making process at the end of the record (assessment and plan). All more recent variations of record keeping share the SOAP format as their genesis.
The SOAP format helped a little for both external and internal uses, but the problems of poor penmanship and nonstandard abbreviations continued to be barriers to good communications. When information was needed from a patient record, it was often necessary for the doctor to draft a letter interpreting the contents of the record. This step is redundant and should not be necessary. The patient record should be clear enough that its contents are understood by anyone sophisticated enough to have use for the information it contains.
The process was further complicated when providers began to report services and procedures to entities other than the patient for payment. Patients could always judge for themselves if they had received the services for which they were billed and if the fees charged were appropriate. They seldom needed to see the patient record to decide that.
When insurance covered the services, however, the company was not present during the examination and, thus, had to depend upon the claim form to determine the content of the visit and the charges for the services. Code numbers from Current Procedural Terminology (CPT) and Inter national Classification of Diseases (ICD) permitted doctors to communicate the content of the encounter and the patient record to the payer. The patient record is central to that communication, in that it supports the doctor’s choice of codes; it contains the evidence that the services billed for were actually performed.
Common language needed
There are hundreds of thousands of health care providers in the United States and thousands of health care insurance companies. If each provider and each payer has its own set of guidelines for keeping patient records and its own guidelines for choosing office visit and procedure codes to bill for services, communication will be impossible. Communication between and among providers and payers won’t be effective until all are using the same rules and language.
CPT defines services
Health care in the United States is slowly developing and accepting a single set of rules and a single language. CPT was developed by the American Medical Association (AMA) and has become the international standard for combining a description of each service with a five-digit code for reporting that service. CPT is copyrighted; anyone using its codes is required to use each code only if the service provided matches the CPT definition of that service.
This is the requirement of CPT, but we all know that is not standard practice. Many payers publish their own definitions for specific CPT codes, and they may differ from CPT definitions. Many providers use a CPT code to report services they’ve provided even though the provider is totally unfamiliar with CPT’s definitions and may not even own a copy of the current CPT guide.
Use documentation guidelines
The Documentation Guidelines were developed jointly by the AMA and the federal government’s Health Care Financing Administration to clarify the connection between the codes and descriptions of CPT and the contents of patient records. The guidelines were first published in 1994 and were updated in 1997. Providers are required to use either the 1994 or 1997 guidelines to choose office visit codes billed to Medicare. Medicare auditors use the guidelines when reviewing patient records to be sure that the services reported and paid for were actually provided.
ICD-9 codes not used widely enough
ICD provides a numeric or alphanumeric code for each medical diagnosis. Most payers require doctors to document patients’ diagnoses using ICD-9 codes.
Thus, the coding systems provide definitions for services and the codes to report them (CPT), guidelines for patient records to support the doctor’s choice of office visit codes (Documentation Guide lines) and code numbers to report the patients’ diagnoses (ICD-9). Those three systems provide the keys to better communication among providers and payers, and yet they have been largely ignored by significant numbers of both groups.
There are many problems and challenges associated with the evolving health care systems in the United States. Each problem and challenge will eventually have a solution, making life better for America’s citizens and its health care providers. Communication has been one of these challenges. Its solution already exists: universal application of CPT, ICD and the Documentation Guidelines.
Solutions can be of no use and will have no effect, however, until they are applied. This is true with respect to this solution, too. Many doctors have already quietly learned about the coding systems and have adapted their medical records to improve communication. How about you?
For Your Information:
- Charles B. Brownlow, OD, FAAO, is executive vice president of the Wisconsin Optometric Association and vice president of operations of Practice Management Inc. Dr. Brownlow is a member of the AOA Eye Care Benefits Center (ECBC) executive committee and the ECBC subcommittee on coding issues. He may be contacted at Practice Management Inc., 5721 Odana Rd., Ste. 102, Madison, WI 53719; (800) 827-1945; (608) 274-5044; fax: (800) 308-7189; (608) 274-2674; email: brownlowod@aol.com.