Templates. They are a standard of practice, a requirement for your EHR, a time saver, and the bane of the medical reviewer’s existence.
Errors are common. Designated templates are used from case to case. This requires key elements of the form to be updated to match the specific case being documented. Common elements in an operative report are: Header, procedure description, pre and post op diagnoses, laterality, access site, vein location and length, technology used, and energy or supply specifics. Obvious, right? Except in reality when practices get busy and notes are completed in a hurry mistakes can be made.
For example, a report may have the header “Percutaneous Radiofrequency Ablation of RT GSV”. The body of the report may however have information stating LT SSV, mention the saph-pop junction or treatment of tributaries and no mention of the RT GSV. This in and of itself is not detrimental, as long as it is caught upon review and a correction is made.
But what happens if the error is not caught and the claim is sent out to the insurance?
As we all know, a large percentage of Phlebology claims are subject to scrutiny in the form of a medical review. Records are requested and submitted to the insurance, and no payment will be made until these reports are gone over by the reviewer assigned to the claim. This reviewer is paid to reconcile the report against the claim submitted, and against medical policy. Any disparity will be noticed immediately which effectively causes the payer to stop the review. Instead, a denial will be generated and the lengthy process of appeals will begin.
During this time you are not being paid for your services, and worse yet, time and energy (not to mention money) will be spent identifying the error, appending a formal correction to the record, compiling a case, and submitting an appeal. Follow-through will take at least 60 days, sometimes over 120 days, and all this time you will be paying someone to “work” the claim.
Coders and reviewers alike read the body of a medical report to ascertain exactly what should be reported. Often I hear feedback that the description in the header of the report is sufficient to determine what was done. This is incorrect. It is the body of the report that makes up the content we code for, and discrepancies here will cause any coder to send it back for clarification. The insurance plans are not so accommodating. They will just deny you and tell you that the service you reported is not supported by your note. It behooves any practice to ensure checks and balances are in place to mitigate these errors.
I also educate providers that we, the coders, are not mind readers. Just because you know the information in your head, if you do not place that information onto your report, it will not be considered when an outside individual looks it over. Be thorough!
The end of the year is a good time to go over practice policies and protocols, and reviewing your templates for content. Be sure to include a good internal auditing process which is a step the well managed practice doesn’t want to skip.
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