Accurate chart documentation is time consuming yet critical.

We are nearing the end of first quarter. How are your resolutions going? If your goal was to review and refresh aspects of your practice, chart documentation is a good place to start. Accurate documentation is critical in any medical practice, and it consumes a lot of physician and staff time.

In this article, we’ll cover what is being documented, how and by whom in order to confirm you are getting the most of their efforts.

What notes are needed?

Documentation varies based on the service provided (exam, test, or surgery), but some consistencies exist. The chief complaint and medical history provide medical necessity for most services, and all notes should support the claim for reimbursement.

Documenting exams

Since the AMA revised the guidelines for coding E/M services in 2021, the CPT book requires a “medically appropriate history and/or examination.” Do not interpret this as “no history is required” — critical components are still needed.

In terms of clinical care, the chief complaint and history help the physician determine the type of exam needed: an external exam to assess a foreign body or a more comprehensive service for the recent onset of flashes and floaters, for example. Additionally, symptoms noted in the history may support a future test or surgery.

The goal in documenting should be “concise yet thorough” — a balance between too little and too much. Experienced ophthalmic assistants and technicians can easily streamline history taking based on the patient’s complaints. For newer staff, consider creating scripts, or “cue cards” based on visit types. For example:

• Cataract consult: complaint of symptoms, eye(s) and activities affected, age of eyeglasses.
• Injury: eye involved, how/when injury happened, if vision is affected, pain level, what treatment has been applied.
• Glaucoma follow up: which eye(s), medications, medication schedule, compliance, complaints of vision change, eye irritation, etc.

From a reimbursement perspective, the patient interview indicates why the patient is present and supports a claim to medical insurance or a vision plan.

Documenting tests and surgeries

The medical necessity for tests and surgeries can be found in the medical history as well as in the physician’s exam-findings notes from tests and care provided to date. For diagnostic services, be sure to document the physician’s order as well as the test results (e.g., print out, images, or measurements) and the physician’s interpretation.

Who is documenting in your records?

Many ophthalmic practices employ scribes to help ensure charting is well done while allowing physicians more time with the patients. Benefits of employing a scribe can include:

• Record completeness
• Legibility of hand-written notes
• Improved productivity
• Improved patient experience since the physician’s attention is not on the computer
• Scribes may also gather tests or prior-visit information pertinent to the encounter.

Of course, there are some restrictions, as well. Scribes:

• Transcribe what a physician dictates but may not elaborate on or make chart entries based on their own interpretations.
• May not document extended ophthalmoscopy (CPT 92201, 92202); only the physician can make the accurate retinal drawings.
• May not make medical diagnoses or order future services.
• May not sign on behalf of the provider.
• Should access records by using a unique log-in ID, not the provider’s access ID.

Requirements regarding scribes in health-care systems, teaching facilities, and hospitals generally differ from physician practices; differences may exist between inpatient and outpatient settings as well.

Also, consider that state rules may apply, and check with your Medical Administrative Contractor (MAC). For example, First Coast Service Options addresses the physician’s need to confirm the scribe’s work in an FAQ on its website: “Medicare policy is not opposed to the use of personnel as scribes. However, the medical record must include documentation that the physician reviewed and confirmed the information stated by the scribe.”

Conversely, Novitas, the MAC for several states, writes “the scribe may document what is dictated and performed in the medical record.” They go on to state: “Documentation of scribed services must clearly indicate:

• Who performed the service;
• Who recorded the service;
• The qualifications of each person (i.e., professional degree, medical title); and
• Be signed and dated by both the physician … and scribe.”

Even with no specific instruction from the local MAC, physicians should attest to the accuracy of the scribe’s notes. The absence of an attestation may cast doubt on the accuracy of the record. Electronic medical records (EMRs) should indicate the provider’s review of the notes.

Identity of the person making chart entries must be obvious. For this reason, best practices include requiring that:

• Scribes log in to document the physicians dictated comments;
• Physicians log in to sign charts (don’t allow scribes to sign charts for physicians); and
• Physicians review, edit and correct the scribe’s notations and attest to the completeness and accuracy.

While scribe training and certification are available, they are not required by all payers. The Novitas’ Scribe Services Guidelines, published in its December 2011 Medicare Report, says “a scribe can be a Non-Physician Practitioner (NPP), nurse or other ancillary personnel allowed by the physician to document his/her services in the patient’s medical record” and requires “the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice … [and] any other relevant regulations.”

Scribes should have legible handwriting and familiarity with data entry. Although they are not responsible for code selection, scribes should have a working familiarity with ICD coding as well.

Access restrictions

Passwords should be kept confidential and not shared between physicians and staff. Also, scribing is different from patient workup and testing, so the same person should not perform these functions concurrently. If the person functions as both a scribe and tech, consider two different log-in passwords to facilitate the distinction for reviewers

Review your requirements for logging in to EMR and practice management systems, and enforce internal policies regarding computer access and protecting passwords. Don’t forget about off-site employees who access your EMR: off-site patient scheduling staff or those doing pre-authorizations and checking patients’ insurance benefits.

Templates and chart forms

While you are reviewing and perhaps revising the instructions on history taking, look at the tools provided for staff to do their job. For paper medical records, there are endless options in templates used in charting.

EMR systems provide a variety of templates, as well. Take advantage of the system’s options for customizing the layout to suit your needs. Get input from the technicians, physicians, and scribes who use the system. Consider a template layout in which the record order flows with the visit, minimizing any duplications or redundancies. OP

Ms. Johnson is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.