Understanding how precise note language will head off claims denials

Q: One of the office managers in our complex told me that there are some things that doctors just shouldn’t write in a note-certain words or phrases will make payers down-code or deny claims. Is that true? 

a: Well, that may be a bit of an exaggeration, although there are surely some terms that may cause an auditor, utilization or quality reviewer to give some charts a closer look, and perhaps to act on it.

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In the beginning of a note, in the chief complaint or HPI sections – you should surely avoid the word ‘routine.’ It doesn’t really add anything and tends to diminish whatever you are describing. 

And be clear about the nature of a visit. There are so many versions of comprehensive exam, comprehensive assessment, CPE, annual exam etc. that it is often difficult to know what  this means. If you are talking about health maintenance, or preventive medicine, say so.

Consult notes often have some very frequent poor word choices. It’s amazing how often visits billed as consults begin with, or contain (sometimes numerous times) the word “referral.” This tends to point directly away from the consultative nature of the visit, and more towards the ‘transfer of care’ version of a visit. Avoid this word in true consults.

Next: Further advice

Often under history we have the old ‘non-contributory’ or ‘not relevant’ type comment in relation to something like family history. This gives reviewers pause: they don’t know whether you decided that the information wasn’t worth obtaining and you didn’t do it, or whether you did it and it was of little value. 

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The codes often require that you obtain this information – so rather than these uncertain terms – just say ‘negative for ____’ something pertinent to the presentation. This can avoid a down-coded claim.

Not many providers do this anymore, but we will sometimes see the phrases ‘exam unchanged’, ‘exam normal’, or ‘remainder of the exam unchanged.’ Unchanged since when? These types of comments of course have no value in the world of counting your way towards physician work Don’t ever use them.

Providers with some knowledge of the medical decision-making tables will write ‘old records reviewed’ or ‘records reviewed’ in an effort to get a couple of extra points for this additional work. But a closer look at the requirement indicates that it says ‘review and summary’ of old records. You need to provide some type of synopsis of what you read, not just that you read it. This is less of a trigger than just an ineffective measure.

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Last, and maybe the most self-deceptive of all, is the plan that says ‘all meds reviewed, patient complaint with all meds, will continue same’ –without mentioning any specific diagnosis, status, or management. 

Next: Should I abbreviate my work?

This may appear to cover a list of diagnosis codes above in the assessment, but it really doesn’t say anything specific, and reviewers get tired of seeing it pretty quickly. As has been said before, if you abbreviate your work, the payer may find a way to abbreviate your payment.