EDITOR’S NOTE: This is the first in a three-part series about the author’s encounter with a physician and his staff regarding the clinical documentation of a patient who had suffered a hairline fracture of the left ankle.

The surgeon’s voicemail was straightforward and urgent: “Based on your audit findings and recommendations, I think we need you here for a face-to-face presentation. We want to know why our medical record documentation requires ‘remediation’ prior to our getting started with ICD-10 training.”

After a quickly arranged flight from my Washington, D.C. office to the great state of Texas, I found myself the center of attention in a conference room packed with providers, coders, billers and other staff. The orthopedic surgeon picked up the conversation as if we were still on the telephone and not a moment had elapsed.

“So let’s take case No. 1 here: walk me through this and explain to me all of the so-called ‘pre-ICD-10 goals’ you have pointed out in your audit dossier, and tell me why we’re not able to jump right into ICD-10 training!”

With that, Dr. Jones (as I’ll call him) slid the patient case file across the conference table to me. Talk about feeling like a sirloin steak thrown into a den of ravenous lions! I quickly opened my laptop, pulled up the client’s audit spreadsheet and slowly started picking apart the case findings one by one, knowing for this practice my report was nothing more than a case of good news wrapped in a few layers of bad news.

“First,” I said, ”let’s establish that this isn’t about finger-pointing. This is a learning opportunity centered on the current status of your MR documentation, warts and all. As you know, I audited a random sampling of your typical office visits under the pretense of ‘how to make your practice ICD-10 ready.’ Case No. 1 was a patient who presented to your office with a ‘painful ankle of a three-day duration; she denies trauma (no falling, slipping, or bumping).’ Your documented diagnostic impressions in combination, with the X-rays done in your office, revealed a ‘hairline fracture, left ankle’ without further detail, and further down the list of patient diagnoses, ‘severe senile osteoporosis’ was noted. The exact leg or ankle bone(s) involved in this hairline fracture weren’t identified by the one-line radiology ‘report’ embedded in the latter part of the office notes. The patient was casted here in your office and you followed her under routine circumstances. The next visit I audited for the same patient occurred approximately 10 weeks later, during which time she was asymptomatic and had near-complete healing of the ankle fracture, also confirmed by X-ray.”

Now I was getting to the awkward part: “Dr. Jones, let’s start at the beginning, with the documentation itself. There are numerous sets of handwriting in the medical record entry for the initial visit, which is undated,” I said. “Also, even though the note is on a form with your practice letterhead stamp at the top, the note itself is not signed, and the various staff annotations are likewise not further identified or authenticated in any way.”

Dr. Jones piped up, “Our notes are all written or dictated and typed on our letterhead forms, so there’s obviously no confusion about who saw the patient.”

“I’m sorry,” I continued, “but case No. 1 wasn’t signed or initialed, and even though there are certain signature compromises when office notes are furnished on practice letterhead, they still must have the treating provider’s signature or initials.  That’s called authentication. I’ll talk more about that in a moment.”

“However, continuing with the documentation itself, given the clinical facts of this case it was surmised by me to be a pathologic fracture secondary to senile osteoporosis – but it was coded as an acute fracture, that is to say, a traumatic fracture, using ICD-9-CM code 824.8, ankle fracture, unspecified, closed,” I said. “And the patient’s next audited visit, which happened to be her final fracture care follow-up visit during which it was documented she ‘is asymptomatic and without complication,’ was likewise coded with the original acute fracture code, 824.8, and not with the appropriate aftercare code.“

I continued: “And to muddy the waters, there are no radiology reports to speak of. The X–ray ‘reports’ (yes, I did the air quotes thing!) consisted of two different one-line references to your radiology film reviews. While these one-liners are succinct, I had to hunt for them by teasing them out of the ‘plan’ section of the notes.“

Dr. Jones interrupted me: “We never dictate X-ray reports; there’s just no need, right? We take full responsibility for our X-rays – they are not sent out for a radiologist’s review. We do that.”

Then he quickly switched gears.

“But the coding, Stacy, you code fractures, so what’s going on?” he asked. With that he turned to a rather stalwart woman who had worked in the practice for 12 years.

I could immediately tell she was primed for a fight.

To be continued…

About the Author

Michael G. Calahan, PA, MBA, is vice president of physician and hospital compliance for HealthCare Consulting Solutions (HCS).

Contact the Author

mikiecal@hotmail or questions@hcsglobal.net

To comment on this article please go to editor@icd10monitor.com

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