Tips for Avoiding Documentation Pitfalls


When aspiring medical professionals dream of their future careers, it’s unlikely that they consider the critical role that documentation plays in the healthcare process. Once in practice, providers quickly realize that documentation has a direct impact on their financial success. In addition to the complexity of documentation rules and requirements, the advent of electronic medical records (EMRs) has introduced a new set of documentation challenges for providers that can lead to red flags for chart audits and paybacks for past claim “overpayments.”

Below are recommendations to help providers—at all stages of their careers—avoid common documentation pitfalls.

Provide Complete Documentation

A patient’s medical record should contain all of the necessary documentation to support the services rendered and billed on that date, as well as the medical necessity of those services. For example, providers must substantiate the medical necessity of tests they order by documenting the suspected conditions that have led to this testing. When a chest x-ray is ordered, does the provider suspect asthma, pneumonia, bronchitis, lung cancer or another lung disease? It is the provider’s responsibility to communicate “the whole story” in the chart so coders can code and bill correctly.

Avoid Mixed or Conflicting Messages

Inconsistencies in a chart trigger red flags and are a common reason for down-coding a visit, and thus receiving less for the service than would have been appropriate. Coders sometimes see the following documentation in different sections of the same chart:

  • Patient presents with cough; and, patient denies cough

  • Patient condition improving; and, patient condition is not improving

  • Conflicting laterality within different sections of the chart

For providers to be appropriately reimbursed for all rendered services, they should carefully review charts for accuracy and consistency.

Resist Copying or Cloning Charts

Some EMRs use templates for patient records, many of which are preloaded with information. When using a template, providers should review every field and modify the content based on each patient’s unique information. For example, the social history section may be pre-loaded with a question about the smoking status of the patient. That question is not pertinent for a young child, but a question about exposure to secondhand smoke would be.

Cloning is a red flag for audits because it indicates that the provider hasn’t accurately documented the encounter. If a payer suspects that a chart has been cloned, they may question the veracity of the entire claim.

Append, Don’t Alter

A patient’s medical record is a legal document, and providers should never alter the original record. Updates and changes should be recorded through addendums or time stamps. Altering a chart without proper documentation is another red flag for auditors.

Avoid Abbreviations

The medical field is rife with abbreviations for diseases, diagnostic tests and services. Many medical abbreviations have multiple meanings and can be confusing, especially to a non-clinical person. For example, “PE” can mean a lot of different things in the medical field including Pulmonary Embolism, Pediatric Echocardiogram and Physical Exam, to name just a few. To ensure accurate coding and billing, avoid abbreviations.

Accurate, clear and complete documentation allows coders and billers to do their jobs more efficiently. Proper documentation also reduces the possibility of payer chart audits resulting in balances due back to the payer for prior overpayment. By following the guidelines above and avoiding common documentation pitfalls, providers can ensure the integrity of their current and past payments received.

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