Reducing Duplicate Documentation

December 29, 2010
Bill Dacey

This physician wonders how to get around documenting the "I saw and examined" clause in every patient record.

Question: I am a physician in a teaching hospital. I know that we need to document physician presence for every encounter. For the volume of patients on my service this means the “I personally examined and evaluated the patient …” language will need to be written 2,400 times a year plus any individualized documentation which means another 2,400 additional handwritten comments, totaling 4,800 a year. This is beyond human performance. Suggestions?

Answer: What I’m reading into this question is that you are asking what can be done to relieve your documentation burden. Here is a quote from Medicare Transmittal 811 on the subject:

“When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system.

“In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination.

“The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if the resident and the teaching physician use macros only.”

In English, this means that you can use a canned macro to supply the “I saw and examined the patient” language as long as it comes from you. I added the emphasis to stress that what Medicare is looking for is the “personalized” first-hand knowledge of the case that will justify and support the payment to an attending. That’s where your emphasis needs to be.

So, to get the payment, you have to leave a paper trail of the work. Whether it is an EHR in the clinic, a handwritten note in an inpatient chart - or some form of template - you need to leave the itemized bill to qualify for the payment.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@ubm.com.

This question originally appeared in the September 2010 issue of Physicians Practice.