Accurate Documentation of the Complaint: Focus on the “Why”

When stating the complaint, many medical charts improperly describe what the physician is expected to do rather than explain what prompted the service.

By Sharon Andrews, RN, CCS-P
 

The documentation in the medical record for any E/M service must include a clear statement of the complaint, which is the reason that the physician provides the service. The complaint is the first thing that should be documented for a patient visit. Yet, many times medical records fail to indicate a true complaint. Instead, the record offers as a complaint a summary of what the physician is expected to do. For example, “✓ left leg” or “skin ✓” or “TBSE.” While it may be necessary for the dermatologist to perform those services, those comments are not appropriate documentation of complaints.

The reason that the left leg or the skin must be checked is the complaint:

  • Suppose the patient has a personal history of a skin cancer. This is the reason for a total skin check at appropriate intervals.
  • If the patient has been treated for a rash on the left leg and is returning for follow up, then the complaint is “rash” or “F/U rash.”

The complaint should direct the documentation of the history of present illness (HPI), the review of systems (ROS), and the past, family, and social history (PFSH).

The complaint along with the HPI, ROS, and PFSH, generally indicates the areas to be examined. The location of the rash is part of the HPI. Documentation of the exam should relate the findings to the areas examined.

Before signing off on any patient record, the provider should review it with an eye toward comprehensiveness and cohesiveness. ASk these questions: Does the record make sense? Is there a logical flow from the complaint through the medical decision making?

Document All Complaints
Documentation of all complaints and findings is important to ensure proper reimbursement. When an E/M service and a procedure are provided on the same day, the E/M service is considered to be included in the procedure (by Medicare and some other payers) if the lesion treated by the procedure is the only complaint evaluated. Therefore, it is vital that all complaints or findings are documented.

If a patient is being examined due to personal history of skin cancer, the E/M is for that reason and not part of any procedure that might result from that exam. The documentation of the E/M should include evidence that the provider examined all appropriate areas for recurrences or new skin cancers. The fact that lesions needing treatment are found does not make the E/M part of the treatment of said lesions.

The diagnosis code for the E/M is V10.83 for BCC or SCC and V10.82 for MM. If a patient has several lesions examined, but some are not treated, the E/M should be allowed and the diagnosis related to the E/M should reflect one of the lesions not treated.

It is important also to adequately document the procedures done on the same day. Can you pull the documentation for each code apart from the rest and have each part stand on its own? If you want to be paid for both services, be sure that both are adequately documented.

 

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About Practical Dermatology

Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.

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