Documentation, Coding, Compliance, and Emtala

I. Introduction

Documentation and coding have clinical, legal, reimbursement, and performance improvement implications. Compliance in this setting refers to the proper match between documentation and coding. While specific rules and interpretations may change over time, we highlight the current basics of these important efforts.

A.

Scribing the events of trauma care requires attention to detail to allow performance assessment and to avoid coding/billing errors. All physician documentation must be legible.

B.

Failure to properly document or bill for services (noncompliance) has legal and financial risks for physicians and hospitals, irrespective of intent. Physicians comply best when the documentation of “who did what and when” is clear.

C.

Coding is assigning a numeric descriptor for the work done (CPT code) and matching it with one or more diagnosis numeric (ICD-9) codes. CPT codes include evaluation and management codes (E&M codes) and procedural codes. The E&M codes describe “cognitive” services such as admission evaluation, ongoing in-hospital care, critical care, and other nonprocedural services provided in the inpatient or outpatient setting. Procedural codes describe operations, bedside procedures, and other noncognitive activities such as outpatient excisions of lesions in the office. Without accurate coding supported by adequate and legible documentation, a physician cannot bill for services effectively.

II. Documentation

Documentation should be carried out from prehospital through resuscitation, operating room, intensive care unit, ward, and outpatient care. The requirements for documentation in these areas differ, and tools should be tailored to each phase of trauma care.

A.

In many institutions, the trauma resuscitation record is a separate document from the trauma history and physical examination. The trauma resuscitation record is usually a nurse-driven tool, whereas the trauma history and physical examination is physician-driven. Frequently, these documents resemble each other and contain much of the same data, but they have distinct purposes. As the electronic medical record emerges, this duplication may not be necessary because the ideal trauma record would include the history, physical examination, and resuscitation. However, for the purposes of discussion in this chapter, they will be considered separately.

B. Trauma resuscitation record

The trauma resuscitation record is generally two to three pages in length and is a permanent record (Appendix C). Frequently completed in duplicate by a clerk or nurse recorder, it is designed to minimize writing by use of check boxes and directed queries. Although most are institution-specific, the following elements are usually included:

• Demographic information should include the patient's name, age, sex, time and mode of arrival, allergies, medications, and significant medical history.
• Initial assessment
  • Initial vital signs and “ABC” notations
  • The Revised Trauma Score (RTS) and/or the Glasgow Coma Scale (GCS) score
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  • Mechanism of injury
  • The trauma team members present (and time arrived) as well as consultants
  • A serial record of vital signs, GCS, cardiac rhythm, pulse oximetry, pupil examination, and procedure times
  • Injury description (anatomic diagram of the body, anterior and posterior, is helpful)
  • Initial procedures and studies
  • An accurate account of fluid infused and blood products transfused
  • Disposition of the patient and notation of family contacts

C.

Trauma history and physical examination (Appendix C)

• The trauma history and physical examination can be written in a standard hospital history and physical examination format. However, most trauma centers have developed a preprinted format similar to the resuscitation record to minimize writing and improve data collection.
• The classic components of a history often cannot be obtained during resuscitation, especially the social history, review of systems, and medical history. Rather than ignoring these (which has coding and billing effects), these items must be documented as “unobtainable” with a reason why this is the case (e.g., “Patient was intubated,” “Patient was nonverbal,” “Patient was critically ill”). To avoid ambiguity, do not use the term “noncontributory.”
• In many hospitals, a formatted, preprinted checklist or flowchart form is used for the admitting history and physical examination. Although a dictated note is not mandatory, dictation using the flowchart as a reference improves legibility and can enhance reimbursement. The history of the present illness should include the major elements of the resuscitation, including the following information:
  • Mechanism of injury
  • Time of the accident
  • Presence or absence of intrusion, entrapment, restraint, or airbag deployment
  • Prehospital assessment and evaluation
  • Inclusion of allergies, medications, past medical history, social history, family history, and review of systems will allow a higher level of coding and reimbursement. These can be recorded in nursing or physician notes, but if the former is used alone, a clear notation of physician review (or “link”) is needed to support coding and billing.
• A format employing the Advanced Trauma Life Support (ATLS) initial assessment outline is used in many trauma centers:
  • Primary survey
  • Resuscitation
  • Secondary survey
  • Definitive care
  • Interpretation of the radiographs, scans, and pertinent laboratory studies
  • When and who removed immobilization devices (e.g., cervical spine) or placed devices (e.g., long leg splint)
• Teaching physician requirements. To generate a bill for services in a teaching setting, the attending physician who supervises house staff must personally provide the service or be present during that service. For the history and examination, the attending physician must either obtain or be present for this, or review the resident history and examination and affirm the key aspects independently, noting the latter in the teaching physician attestation note. This allows the teaching physician to link to the resident documentation, supporting optimal billing. The phrase “Seen and agree with above” is inadequate. Teaching physicians can link to resident histories and physical exams (if done together or confirmed). On the other hand, the teaching physician can link only to nurse, student, or other extender histories but not to physical exams.
  • The trauma history and physical examination record should have a separate area for the attending physician to sign with the accompanying (or similar) statement: “I have evaluated this patient, including a review of the

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    history, physical examination, and laboratory and x-ray studies, and have performed or supervised the procedures outlined in this resuscitation record.” However, an additional terse note by the attending that includes brief detail on the four components of care is preferred: history and medications, physical examination, studies, and plan.
  • If billing is planned for any procedures, the attending or supervising physician must either clearly note that he or she performed the procedure or was present “elbow to elbow” (or using another clear statement of bedside presence) with any trainee during the procedure. Simply stating “I supervised the chest tube insertion” is inadequate. For those procedures that take 5 minutes or less, the attending physician must be present and document his or her presence for the entire procedure. For those requiring more time, the attending physician must note the “key portion(s)” of each and his or her bedside presence plus note immediate availability for remaining portions of the procedure. For example, skin opening and closure is often not a key portion, whereas intra-abdominal exploration or repair is a key portion. A supervising physician cannot attest to two key portions occurring simultaneously in different patients (i.e., one cannot “be present or supervising” in two places simultaneously). There are no clear guidelines on what portions of procedures are “key”—the supervising physician must be clear and reasonable when defining this part of care.
  • Critical care time is that spent by a teaching physician in the care of one patient with life- or limb-threatening or impending life- or limb-threatening illness or injury (Section III). It includes bedside care, consultations, laboratory and radiograph interpretations, and discussion with family or other health care providers. Only the attending physician can provide and document billable critical care, and the time can be summarized. Any note should be specific (e.g., “I spent xx minutes of critical care time providing care, excluding procedures”). Similar to procedures, critical care time cannot be billed for two patients at the same time interval, although it can occur sequentially.
  • All notations must be clearly generated by the attending physician—either handwritten and signed, dictated and signed (some insurers allow electronic signatures), or personally checked off (if a template used) and signed, with clear dates and times included.
  • Procedural analgesia and sedation documentation must be distinct from any procedure note (and cannot be performed by the same attending doing the procedure if separate billing is desired). It must include a pre-and post-procedure exam, a brief description of the regimen and effects (augmented by nursing notes/checklist), and note recovery time/status and total time spent by the attending physician (the latter analogous to critical care documentation).
• The following guidelines should be used to document injuries. Diagnoses should be as specific as possible, because the severity scores assigned are affected by the documentation provided by the physicians.
  • Central nervous system (CNS) diagnoses
    • Document the size of brain lesion, in centimeters.
    • Specify type of brain lesion—epidural, subdural, parenchymal.
    • Indicate duration of loss of consciousness.
    • Include neurologic deficits.
    • Document cerebrospinal fluid (CSF) leak, hemotympanum, perforated tympanum, Battle's sign, and raccoon's eyes.
    • Specify cord syndromes as incomplete (anterior, posterior, central, or lateral) or complete, and note their level, if possible.
    • Note vertebral body compression fractures.
  • External injuries
    • Document size and location of contusions and abrasions.
    • Document length and depth of lacerations.
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    • Specify involvement of ducts and vessels.
    • Document volume of blood loss.
    • Specify avulsions and tissue loss >25 cm².
    • Specify suspected bullet wounds by size, location, and presence of soot or powder burns. Do not use the terms exit wound or entrance wound.
  • Injuries to internal organs
    • Classify length and depth of laceration or perforation of internal organs. Use a grading system if applicable (Appendix B).
    • Specify size and location of hematomas.
    • Document involvement of vascular system.
    • Specify blood volume loss (recognizing variability).
    • Document any urinary extravasation or fecal contamination associated with injuries to urinary and gastrointestinal (GI) tracts.
  • Blood vessel injuries
    • Specify complete versus incomplete transection of the vessel.
    • Document any segmental loss.
    • Name the specific vessel, if possible.
  • Orthopedic injuries
    • Specify fractures as open or closed.
    • Document comminution or displacement, angulation.
    • When making the diagnosis of crush injury, document degree of destruction of bone, muscle, nerve, and vascular system of the extremity.
  • Facial injuries
    • Describe all lacerations, swelling, tenderness, deformity, and fracture, and try to use the designation of Le Fort I, II, and III fractures if applicable.
    • When intra-oral lacerations occur with facial fractures, indicate communication with the fracture.

D. Operating room dictation

The operating room dictation should include efforts at ongoing resuscitation and, if dictated by a resident, should have a notation as to the presence of the attending surgeon during the key portions of the case. A written brief operative note should be placed in the patient's chart to help guide the intensive care unit (ICU) team and other consultants who may be asked to see the patient until the dictated operative report is returned.

• Similar to other documentation, an attending/teaching physician note should be authored independent of any trainee note to attest to the procedure and presence (whole event or key portions) and availability during non-key portions. Again, this latter note need not be lengthy.
• The surgeon may request a higher than usual fee for an operative procedure under certain circumstances by appending the -22 modifier to the CPT code. These circumstances include increased risk, difficult procedure, over 600-mL blood loss, contamination control, prolonged operation, and obesity. The operative note dictation should clearly indicate the circumstances for the increased fee request.

E. Intensive care unit

• ICU notes should follow a prescribed template outlining the complexities of care. All entries should document the date and time. If written by a resident, a notation should be made that the patient was seen with an attending physician when that occurred.
• The ICU note should be structured to include
  • Hospital day
  • Diagnoses
  • Surgical procedures
  • Consultants
  • Current problems
  • System review
    • CNS
    • Pulmonary
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    • Hemodynamic
    • GI
    • Musculoskeletal
    • Infectious disease
    • Skin and wounds
  • Laboratory studies and other studies (not covered in the system review)
  • Medications
  • Plans
• The structured ICU note can be written or typed into a computer template and attached to the chart.
• A notation from the resident that the attending physician was present at rounds is useful, when appropriate. However, a supplemental note by the attending physician is necessary for reimbursement of critical care codes and should include the following five components:
  • Diagnosis or problem
  • History, including medications, major events, and other information relating to the patient's hospital course
  • Physical examination, with specific mention of the head, chest, abdomen, and extremities and inclusion of laboratory and other diagnostic studies
  • Plan, which reflects the complexity of the decision making
  • Time spent providing critical care with a notation excluding time spent on procedures that are not bundled (included) with the critical care code

F. Ward. Record date and time of all entries

The ward note also should contain the five components just listed and, when written by the house staff, should acknowledge the presence of the attending physician. The attending must, however, include a note detailing his or her specific care or actions.

III. Coding

A. Overview

• Basically, two coding systems are used. CPT (current procedural terminology), published by the American Medical Association (AMA), is widely accepted as the physician component of billing. There are three components of the CPT codes:
  • Procedures
  • E&M (evaluation and management)
  • Modifiers. ICD-9-CM (International Classification of Diseases, Ninth Revision), developed by the World Health Organization, provides the diagnosis codes necessary to support both physician and hospital billing (ICD-9 procedure codes are also used for hospital billing). Lack of understanding by physicians that a CPT code (for procedure or evaluation and management by a physician) must be accompanied by an ICD-9 diagnosis code(s) is a major obstacle in reimbursement for trauma and critical care.
• Most CPT procedure codes are straightforward. Use of modifiers to indicate special situations is challenging because payers vary considerably in their recognition and acceptance of modifiers. Examples of these special situations include two surgeons, multiple or bilateral procedures, discontinued procedures, surgical team, distinct procedure, repeat procedure, shared procedure, preoperative evaluation only, surgery only, and so forth. However, it is the E&M coding for trauma and critical care that presents the greatest challenge for providers because of the ever-changing and complex rules for documentation. The documentation components, rather than the severity of injury or illness, determine the code. With this in mind, what follows are typical patient examples and potential use of E&M codes for trauma and critical care, assuming appropriate documentation (these rules are too lengthy to include).
• Global surgical fee or package. There is a long-standing surgical tradition that the surgeon should provide appropriate pre-and post-operative care to

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  patients as an integral part of the procedure. This tradition has become standard operating practice for payers. Payers pay surgeons one lump sum, the global surgical fee, for both the operation performed and the postoperative care delivered (beginning on the day of the operation). Postoperative visits in the hospital and in the office are included in this fee, as is any service that would normally be provided in the postoperative period (such as removing sutures). Typically this includes activities in the 90 days following the procedure. Centers for Medicare and Medicaid Services (CMS) guidelines define a postoperative visit as a follow-up visit during the postoperative period of the surgery that is related to routine recovery from the surgery. Complications following surgery are also included in the global surgical package. Per CMS guidelines, complications following surgery are defined as all additional medical and surgical services required of the surgeon during the postoperative period of the surgery that do not require additional procedures in the operating room. In general, this refers to complications directly related to the surgical procedure.
  • There are many instances when a patient develops a problem in the postoperative period that is either out of the scope of the normal postoperative course or unrelated to the surgical procedure. A wound infection would be an example of a complication that is directly related to the surgical procedure and falls under the global surgical package. A postoperative myocardial infarction after a colectomy is not a routine complication and is unrelated to the surgical procedure itself and therefore a separately billable entity. To distinguish a service as not being part of the global surgical package, a physician must use a modifier so that the payer recognizes the service as distinct from the surgical procedure.

B. CPT coding for evaluation and management of the trauma patient

• Critical care codes are used for evaluation and management of a critically injured patient requiring constant attendance (includes peripheral IV, venous and arterial blood draw, NG and urinary catheters, arterial blood gases, interpretation of hemodynamic or cardiopulmonary monitoring and chest x-ray, and ventilatory management).
• (99291: 30–74 min, 99292: 75–104 minutes). These codes are used when a critically injured patient requires continued bedside management during initial resuscitation or subsequent critical care. This includes continuous physician attention during transport to CT scan suite, angiography, operating room, or ICU. Three major requirements for using the critical care E&M codes are:
  • Clinical condition criterion: “There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient's condition which requires the highest level of physician preparedness to intervene urgently.”
  • Treatment criterion: Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition.
  • Documentation of time: For example, “Critical care time: 45 minutes excluding procedures.”
  • Procedures such as chest tube, central line, diagnostic peritoneal lavage (DPL), and arterial line are not included in this code and should be billed separately. A modifier (-25) should be added to the E&M code if a procedure is done on the same day to clarify that the global surgical package does not apply.
  • These codes are also applicable to subsequent daily critical care management, utilizing the same time parameters.
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  • Critical care codes (99291 and 99292) may be used to describe care provided in the postoperative period if the care is for conditions not included in the global surgical package as long as the documentation clearly describes the condition for which critical care is required, the appropriate level of critical care delivered, and lists the diagnoses supporting this level of care. Note that the diagnoses must be different from those used for the operative coding and that an appropriate modifier must be used to indicate that the assumptions under which the global surgical package is applied have changed. In other words, the patient has developed a condition (described by the new diagnoses) that is not generally encountered in the routine postoperative care of patients undergoing the operation in question.
• If initial resuscitation does not rise to the level of critical injury and the care rendered is not critical (by the surgeon's judgment and documentation), then the codes for initial hospital care (99221–23) should be used, depending on the complexity of decision making and time spent with the patient.
• (99233): Subsequent hospital care, often used in the ICU or step-down unit for patients with complex conditions requiring a high level of care. This code can be used if the ICU care is for reasons other than specific postoperative care. For example, this code can be used for a patient with a closed head injury, multiple rib fractures, and a femoral fracture who had an exploratory laparotomy and splenectomy because the ICU care is primarily for reasons other than postoperative splenectomy.
  • Postoperative care for an isolated splenectomy would be included in the operative code.
  • Procedures such as chest tube, central line, DPL, and arterial line are not included in this code and should be billed separately (modifier required).
  • Time spent off the unit in review of patient's data cannot be reported, so it is useful to review laboratory studies and images, write or dictate notes, coordinate patient's care (e.g., discussion with consultants), and conduct family conferences in or near the unit where the patient is located.
• (99232): Subsequent hospital care characteristically performed in the intermediate or step-down unit when evaluated for reasons other than postoperative care (i.e., a postsplenectomy patient with a head injury, pulmonary contusion, and pelvic injury who has been extubated and is in a step-down unit for cardiac or neurologic monitoring).
  • These codes do not apply to care of isolated postoperative injuries because they are included in the operative code.
• (99231): Subsequent hospital care, usually rendered on the floor or ward. This is for follow-up evaluation on the medical surgical floor of the nonoperative or operative trauma patient for reasons other than the postoperative care. Total time is typically 15 minutes.
• (99223): Initial hospital care for stable trauma patient with significant injury. Includes history and physical examination and complex decision making. An example is a 24-year-old man with a fracture-dislocation of the cervical spine, neurologically intact, or a 54-year-old woman with stable vital signs, awake, with multiple contusions and abrasions with a seat-belt sign without peritoneal signs who undergoes an abdominal CT scan. The documentation must reflect the level of care rendered as it is the documentation, not the patient's condition, that determines the level of the code applicable.
• (99222): Initial hospital care for a stable trauma patient with a potentially significant injury. Includes a history and physical examination and moderate decision making. An example is a 65-year-old man with a cerebral concussion and multiple contusions and abrasions.
• (99221): Initial hospital care for a stable trauma patient who has no apparent significant or potentially significant injury but will require hos-pitalization. This includes history and physical examination and straightforward decision making. For example, this code may be used for a 22-year-old

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  man, intoxicated, with multiple contusions and abrasions, triaged to the trauma center primarily on the mechanism of injury.

C. Trauma ICD diagnostic coding

• Introduction. Billing for professional services begins with diagnoses for which care was rendered. Most claim forms accommodate four diagnoses. Since 1988, the Health Care Financing Administration (now called Centers for Medicare and Medicaid Services, CMS) mandates the use of the International Classification of Diseases (ICD) for diagnosis reporting; most other payers have followed suit. Proper ICD coding can decrease the number of claims sent to manual review, thereby optimizing timely reimbursement. Several principles should be applied whenever possible to ICD coding.
• Principles and examples
  • ICD coding is contained in two volumes, Volume I (the tabular list) and Volume II (the alphabetical list); use both.
  • “Unspecified” and “other” codes should be avoided.
    • Example: You wish to code for blunt hepatic injury. Volume II reveals “Injury, internal, liver 864.00” and “Laceration 864.09.” Volume I, however, lists the entire classification scheme for closed hepatic injury with detailed descriptions for each code (e.g., “864.03 Injury to liver, laceration involving parenchyma but without major disruption of parenchyma; i.e., <10 cm long and <3 cm deep”). Using Volume I lets you choose the best description and avoid “other” (864.09) or “unspecified” (864.00).
  • Diagnoses should reflect information known to you at the time the billed service was rendered. Each CPT code is linked to only those ICD codes related to that CPT code.
    • Example: You are consulted regarding a patient who has been assaulted and also stabbed in the abdomen. He was unresponsive in the field but is awake, although incoherent during your evaluation. He has right lower quadrant tenderness. Diagnoses accompanying your emergency department consultation claim are (1) “879.2 Open wound, anterior abdominal wall, uncomplicated”; (2) “789.63 Abdominal tenderness, right lower quadrant”; and (3) “850.1 Concussion with brief loss of consciousness.” You perform a DPL. For this procedure, your diagnoses are 1 and 2. DPL is positive, and at laparotomy you repair two distal ileal holes and one ascending colon hole. For the operation, you list (1) “863.39 Open injury, small intestine, other or multiple for CPT 44603 (repair multiple small bowel)” and (2) “863.51 Open injury, ascending colon for 44604 (repair colon).” Remember to use the —51 modifier to specify which procedure will be paid at 50% (Medicare no longer requires this but other payers may).
  • ICD diagnoses must contain fourth or fifth digits where required. Failure to use required digits often leads to manual review.
    • Examples: 789.63 Abdominal tenderness, right lower quadrant compared with 789 Abdominal pain and tenderness. 863.51 Open injury, ascending colon compared with 863.50 Open wound, colon.
  • Thorough ICD coding supports CPT coding for critical care services and for complex evaluation and management services. Not all ICU patients require critical care services daily, and auditors are likely to visit physicians with perceived excess critical care or complex visit charges.
  • Initial diagnostic code selection can have an impact on reimbursement for services provided later in the patient's course. For example, critical care services performed by the operating surgeon are normally not reimbursed during a postoperative global period. However, if the diagnostic codes for the operation are for injury, fracture, burns, open wounds, or other trauma, that surgeon also can charge and collect for critical care services.
  • Use of E or V codes as primary diagnoses often leads to manual review or to automatic denial. E or V codes can be appropriately used in addition to

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    other ICD codes, although they should not replace non-E or non-V codes. V codes can be appropriate as primary diagnoses for “no charge” visits.

IV. Emtala

Beginning in the mid-1980s, federal legislation evolved to protect patients seeking emergency care. Initially referred to as “antidumping” laws, these actions have evolved into the Emergency Medical Treatment and Active Labor Act (EMTALA). All hospitals and providers that offer emergency services through a dedicated emergency department are bound by EMTALA. In 2005, clarifications and alterations to the act were disseminated.

A.

EMTALA states that any person seeking care for an emergency condition (including trauma care) must receive a screening examination and stabilization, irrespective of the ability to pay. Simply arriving at an emergency department for care of a clearly nonemergency condition does not trigger an EMTALA obligation.

B.

The providers and hospitals must provide and document care, or document refusal by a patient with capacity and the knowledge that care will be provided without financial concerns. All life- and limb-threatening injuries must be sought and stabilizing care given.

C.

Hospitals must have policies that ensure physician availability (including functional on-call lists of providers across specialties) to provide this initial emergency care. EMTALA does not proscribe specific call regulations, but requires policy that addresses needs and local resource concerns.

D.

Scheduled outpatient ED visits (done to ease care delivery), direct admissions to the hospital (who may traverse the ED), and inpatients no longer trigger for an EMTALA obligation (though previous interpretations included these populations).

E.

The screening examination and stabilizing actions are not defined in the statute. Based on interpretations and case law, these should be similar to those provided to any patient presenting with the same symptoms or findings. This means the same or similar tests by the same or similar providers (e.g., a nurse screening examination would not suffice unless this was the only examination done routinely for all patients with that complaint). Definitive care is not mandated. The only exception to the stabilization requirement is when attempts to do so would jeopardize the patient's health or outcome.

F.

Transfer to a more appropriate facility can occur after this screening and stabilization have occurred if the receiving facility offers services not available at the original site. Trauma centers often receive patients for this reason from nontrauma centers or lower level centers. The transfer must be accompanied by notification and acceptance between providers, documented agreement by the patient (if capable), and all pertinent medical records. Local policy and practice must ensure these steps and documentation.

G.

EMTALA covers any hospital property—including clinics and other care sites, attached or offsite—held out to provide emergent care. A recent interpretative clarification states that sites that do not provide emergent care are excluded (e.g., dialysis centers, radiology facilities, etc.).

H.

The obligation begins with patient arrival to the facility. That includes patients who reach the hospital security entrance, waiting room, driveway, and sidewalks (if for the purpose of seeking care). Also, patients in an ambulance requesting transport to a hospital are covered if the ambulance is owned or directed by the desired destination hospital's personnel, but not if under other conditions such as a municipal service (another change from previous interpretations).

I.

The possible penalties for failure to comply with EMTALA include imprisonment, fines (with multiple violations possible in a given case), and potential exclusion from Medicare for up to 5 years. The fines can be tripled in selected circumstances where egregious behavior exists. These penalties are separate and unrelated to civil actions (i.e., malpractice).

J.

Providers who send or receive patients have an obligation to report violations when they have direct knowledge of a violation (no obligation exists for informal or secondhand awareness).

K.

The best ED and trauma bay approach is to evaluate and treat all patients the same, and ask insurance information only after the initial care and plan is complete.

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Axioms

• Notes should be factual. Avoid the temptation to express nonmedical judgment or disappointment (e.g., “sequential compression boots found at foot of bed because of poor instruction” or “patient not taken for scan because of inadequate number of staff on floor”).
• All documents, and any changes, should be dated and timed, and single strikethrough used to correct text (rather than attempts to remove) when handwritten charts are employed.
• Realize that payers recognize what you do and document, not just what you do. To minimize audits and denials, complete notes—especially for operative services, procedures, and critical care—as soon as possible (within hours rather than days to weeks).
• Teaching physicians must personally provide care to bill professional fees in a training setting. They must view care or review housestaff notes and independently confirm findings, or do a complete examination alone.
• Teaching physician notes need not be lengthy and should link to any resident and nursing documentation. Do not write “Seen and agree with above” alone if billing is planned.
• To avoid EMTALA problems, care for all patients first, leaving payment or insurance questions until after the resuscitation and emergent care is complete.