Pitfalls of Extensive Documentation in the Emergency Department

INTRODUCTION

Every emergency patient encounter requires documentation, and charting is expected to be thorough and accurate. Aside from being a legal document, the emergency department (ED) medical record has clinical and financial functions. Clinically, the medical record communicates vital information to providers—whether the inpatient team, an office-based physician, or the emergency medicine physician at successive visits. Medical records also form the basis of billing. Compensation is based on the work performed as determined by coding. Generally done by a third party, coding is the process of deconstructing the ED visit into a level of service and the procedures performed.

Relative value units (RVUs) represent an arbitrary measurement of physician work; they are measures of value based on the Medicare reimbursement formulae for physician services.¹ RVUs extracted from medical records factor into the compensation that the physician contributes to the department. In the unique clinical setting of the ED, in which patients present unpredictably with varying degrees of acuity and complexity, RVUs track a confusing mix of cognitive and procedural efforts. Unlike their colleagues in the surgical and medical departments, ED physicians generally have no knowledge of how many RVUs will be generated for work with a particular patient. Not surprisingly, billing efforts on behalf of emergency physicians require trained billing specialists, either outsourced or in-house.

Different evaluation and management codes apply to the context of a patient encounter, such as in-hospital or outpatient visits, and factor into the level of service. The level of service ranges from 1 to 5, with an additional designation for critical care, and is determined by how much clinical information is documented in the history, review of systems, physical examination, and medical decision-making. In general, the more complex the visit, the higher the level of service.² Whether the physician is a direct employee, a contractor, or a member of an independent group, documenting and billing for all work legitimately performed is imperative.³ Trainees are generally directed to document extensively.⁴ Supervising physicians may also be encouraged by administrators or billing services to provide appropriate documentation to qualify for the highest appropriate level of service.

The widespread use of electronic medical records allows for fast and easy documentation with prepopulated templates and phrases. Templated medical records are designed to efficiently capture required histories (present illness, past illnesses, social and family history, review of systems), objective findings, and data review to justify coding levels. Emergency medicine practice entails multitasking of clinical problems involving varying degrees of acuity and complexity. The relative ease of computerized charting can allow for careful review of systems pertinent to the chief complaint, and an unsuspected issue may shed light on the presenting complaint. For instance, a patient presenting with leg edema who is found to have pruritis on review of systems would suggest a liver pathology as the cause. Further, an incidental finding could lead to the discovery of an unrelated but significant pathology. For example, a patient presenting with ankle pain who is found to have unintentional weight loss on review of systems may suggest an undiagnosed malignancy. Thorough use of a review of systems may provide the physician with diagnostic acumen; however, an extensive review of systems may also lead to notation of system complaints that are not thoroughly investigated. Casual reference to incidental findings can be medicolegally problematic if the findings are not fully investigated or followed up.

What might be considered overdocumentation can also result in overbilling. Third-party payers—such as government agencies, insurance companies, health maintenance organizations, and employers—review emergency medicine group practices. A group with high levels of complex care billings could invite audits, resulting in paybacks and penalties. In rare cases, charges of fraud have been leveled. For instance, Prime Healthcare Services, Inc. agreed to pay $1.25 million to settle upcoding allegations regarding falsified information about patient comorbidities and complications.⁵ As medical billing companies process healthcare encounters into claims for insurance companies and patients, they can provide protection against potential penalties. To protect physicians and themselves, billing specialists may intentionally bill a medical record documented at a level 5 to a lower level. In other words, careful charting by a physician to justify a high level of service may be reimbursed at a lower level.³

Another consideration related to overdocumentation is that time spent charting may be at the expense of patient care. An observational study of office-based physicians showed that physicians spent 2 hours on the computer for every hour of patient time.⁶ Although some charting is often done after the scheduled end of shift, this study demonstrated that charting takes more clinical time than direct patient care.

Conceptually, given a cohort of ED patient encounters, opportunities for reimbursement may be missed when charting is done in the context of a busy ED. Again, conceptually, given the same cohort of emergency patients, there must be a level at which all possible billable issues have been captured, and further documentation, from the point of view of billing, would be overdocumentation.

While it is arguable to what degree extensively detailed charting may be clinically valuable, a common assumption is that adding more information to documentation will improve reimbursement. To what degree this assumption is accurate is the focus of this study.