Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Digging Deeper into Clinical Documentation

By Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI

Welcome to Compliance Corner, a department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This resource aims to help you navigate recent changes to Current Procedural Terminology® (CPT®) Evaluation and Management (E/M) guidelines for office visits, which became effective January 1, 2021. Written by the American Medical Association (AMA), these guidelines contain new methodology and new definitions, both of which affect the way you as providers document the account of the patient visit.

Digging Deeper into Your Clinical Documentation
Last quarter we did a mini check-in with the 2021 Documentation Guidelines. This quarter it is time to dig deeper into the clinical documentation in the medical record and consider how an auditor will use the clinical documentation to determine the three parts of medical decision making.
We must start with the most basic information concerning the importance of the medical record.

Medical Records will be used as…
1. As evidence in Professional Misconduct Prosecutions
2. As evidence in lawsuits, hearings, or inquests
3. Components of external reviews
4. Audits, peer assessments, etc.
5. To investigate billings

The legal medical record serves to:
1. Support the decisions made in a patient’s care
2. Support the revenue sought from third-party payers
3. Document the services provided as legal testimony regarding the patient’s illness or injury, response to treatment, and caregiver decisions
4. Serve as the organization’s business and legal record

The Professional Perspective
When we consider coding and billing, we must think about the professional side of clinical documentation. The importance from a coding and billing perspective would be the following:
1. Increasing regulatory demands for evidence-based patient care.
2. Increasing use of the electronic medical record (EMR), including issues involved with implementing the EMR and the need for continuous accuracy and compliance.
3. The healthcare industry, with the use of the electronic resources, can now afford to aggressively investigate and enforce compliance through audits, recoupment, and denial of payments.
4. Patient involvement—more patients are requesting their medical records. Visit summaries are provided to the patients as part of meaningful use and advancing care information under Merit-based Incentive Payment System (MIPS).

Meeting Requirements
How do we combine all these aspects of the clinical record so that the required information does not create an unnecessary burden on the provider?
If we consider the following recommendations, that are primarily based on correct documentation associated with coding, the rest of the requirements should just fall into place.

When CMS released the 1995 Documentation Guidelines the definition of a complete medical record was provided. The guidelines may have gone away; however, the intent of what should be in the medical record has not gone away
Per CMS, medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. The medical record facilitates the following:

  • The ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time
  • Communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care
  • Accurate and timely claims review and payment
  • Appropriate utilization review and quality of care evaluations; and collection of data that may be useful for research and education

How will an auditor use the clinical documentation to determine the three parts of medical decision-making?
Reviewing the above noted items from CMS would lead to the auditor, coder, provider asking the following based on the documentation of the patient encounter:

  1. Does your documentation convey all this information?
  2. If an auditor were to review your documentation, would medical necessity be evident?
  3. Would you be able to answer yes to ALL of the following questions? If not, an auditor may not be able to follow your medical decision-making thoughts through your documentation.
  4. Is the condition acute or chronic?
  5. What is the status of the condition?
    • Has the patient met goals?
    • Is the patient taking a medication for this condition?
  6. Is the complexity of the condition affected by comorbid conditions?
  7. Has the past, family and/or social history (PFSH) been reviewed and updated by the reporting provider (when medically appropriate)?
  8. Has the review of systems (ROS) been reviewed and updated by the reporting provider (when medically appropriate)?
  9. Did the exam provide information that is relevant in the assessment?
  10. Did the documentation of the exam include the body area or organ system related to the chief complaint?
  11. Was implication of lab results documented?
  12. Does the assessment match the findings?
  13. Are appropriate signs and symptoms documented?
  14. Were images reviewed or reports read?
  15. Is the medical necessity for independent interpretation outlined?
  16. Is there documentation to support the reason for ordering of tests or imaging or other studies?
  17. If not documented, is the rationale for ordering diagnostic and other ancillary services easily inferred?
  18. Assessment, clinical impression, or diagnosis?
  19. Is there a documented plan for care?
  20. Are appropriate health risk factors identified?
  21. Is the patient’s progress, response to and changes in treatment, and revision of diagnosis documented?
  22. Problem List versus Problems Addressed: Does the documentation distinguish between the two?
  23. Does the documentation support medication management or is there just a list of medications?
  24. Surgery—Have risks been identified and documented?

What information might cause someone to question the clinical significance of the medical record?
If a provider or auditor can answer yes to any of the following, based on the documentation of the patient encounter, then the clinical significance of the medical record may be in question.
1. Is there contradictory information found in parts of history and exam?
a. Edema noted in assessment, noted as negative in the exam
b. Past complaints, now resolved, per assessment and noted as positive in history
2. Cloned notes (hx and exam)
3. Copy and Paste (hx and exam)
4. There is no documentation to support the conditions noted in the assessment
5. Was there any portion of the documented exam that appeared clinically unnecessary or irrelevant?

Ensuring a Complete and Compliant Medical Record
The simplest answer to a complete and compliant medical record is to document the following for each visit to reflect that the information is current for that date of service.
✔ Why is the patient being seen?
✔ Indicate if the problem is chronic or acute
✔ The status of chronic conditions
✔ Document if external records or tests were reviewed
✔ Document the plan of care for each condition
✔ Document which medications are being managed and at what regimen
✔ Document any risks that were addressed during that encounter

If you have questions or suggestions for particular topics to cover in upcoming issues, please let us know at

Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI, has been working in the field of medical coding and auditing for over 30 years. She has been a Certified Professional Coder (CPC) since 1994, attained her Certified Outpatient Coder (COC) for facility-based coding in 2005, and is a Certified Professional Medical Auditor specializing in Evaluation and Management (E/M) Coding. She has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She has served on the American Academy of Professional Coders (AAPC) National Advisory Board and is past president of AAPC’s Richmond and Charlottesville, Virginia, local chapters. Kipreos is president of Practice Integrity, LLC, where she manages a national client list and provides compliance monitoring for provider documentation. She currently resides in San Diego, California.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

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