Updated on: November 20, 2014

Documentation: Intent Versus Content

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Original story posted on: November 18, 2014

 

Electronic medical record (EMR) products have brought automation to the healthcare industry, but does healthcare really need to be automated?

The intent of creating a storehouse of all health information was such that when you go to a new provider they now would have all of your records (or when you get in a car wreck out of town, you would arrive in the ER and they know your allergies; or most importantly, you could store demographics so obnoxious paperwork is not required at every office you visit).

This is the part of automation that the healthcare industry truly does need, and while we see some things slowly coming together, we are years away from achieving this level of success. With EMR automation, we have seen records that can meet every requirement of documentation guidelines, but lacking the medical complexity that should be associated with the medical necessity of the encounter.

Providers are going through the process of creating their documentation through the EMR, noting that for once their records consistently meet the requirements for the levels of service they are billing, only to have them rejected as not meeting such requirements through a carrier audit process. This is because the automation of the record has removed the empathetic approach in documentation that existed when the provider was able to focus on the content and not on clicking the appropriate buttons on an EMR. 

Medical documentation is created in an effort to convey what transpired between provider and patient on any given date of service and for any such service that was performed. Often, what happened during the encounter that needs to be included in the medical record becomes lost, failing to make it into the documentation. It seems that the medical record has somehow lost its value over the years, and rather than being a document of high value and meaning, it has become a mere step in the process of reimbursement.

Creating documentation has become a task – even a chore, if you will, to some providers – associated almost exclusively with being reimbursed and trying to keep the reimbursement. It is for this reason (and others) that most documentation is lacking in content while focusing more on intent.

Medical records end up having an abundance of content, but the content often is lacking in flow, complexity, and the goals of the patient care. The automated documentation ends up supporting a very high level of service through the bean-counting process of scoring the medical records, but when the same records are reviewed for medical necessity, they are down coded significantly. As a means of a defensive response to such findings, providers rely on referring to what was intended in their documentation, and on what an auditor should therefore assume (which, as auditors, we know is not allowed).

The intent must be included within the creation of the documentation of the encounter in order to accurately define the medical necessity, which is easily done when the provider is able to transfer exactly what happened in the room with the patient into the words that create the medical record.

The intent is the most valuable portion of the documentation, as it truly defines the medical necessity of the service. So, when we have records that include a lot of content and the provider expects us to assume the intent, we have a record that is lacking in the complexity necessary to define the medical necessity. Furthermore, a provider should not want an auditor or even another provider to need to assume the intent. The key to making this happen for providers is not found in giving up on EMRs or making huge changes to the ways in which they practice medicine, but rather to work with what you have. 

Most EMR products have free texting ability somewhere within the note. If the provider will text their thought processes on each patient, their records will not only have the content components met through the EMR process, but they will have the intent needed to demonstrate the medical necessity. In free texting, the provider should be defining the patient’s severity according to the patient through a brief overview of the history findings and then incorporate his or her own assessment of the medically defined severity of the patient and the plan and/or approach for treating the problem. Such documentation does not have to be lengthy, but rather it should be rich in quality, and since there are no rules requiring certain portions of the record to be in specific areas, this information could be placed pretty much anywhere (although within the plan of care would make the most sense). 

Tweaking the documentation in this way will take a minimal amount of time and effort but will truly expand the medical complexity and clearly define the intent of the visit. This will not only help support the level of service billed, but it could also lead to documentation that supports a higher level of service. 

About the Author 

Shannon Deconda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. Deconda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. Deconda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies.

Contact the Author

sdeconda@namas.co

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