Healthcare professionals are being called on to take ownership of a thorny documentation issue.

“Note bloat” was a term I heard recently while visiting a client, and it completely resonated with me as an accurate description of documentation being produced in the healthcare industry at this time.

So, what is it? Note bloat is the act of creating documentation that could support the highest level of relevant place of service- (POS)-oriented evaluation and management (E&M) regardless of the medical necessity or complexity of the patient encounter. In other words, it’s documenting a level 5 for a splinter in the finger.

This article is not going to focus on the documentation scoring process, nor is it meant to discuss the medical necessity associated with such an encounter. Rather, this article centers on why providers, physician and nonphysician providers (NPPs) alike, have resorted to creating documentation that is encompassing of any level of services regardless of the nature of the presenting problem of the patient.

Quite honestly – and let’s address this head-on – I think it is the fault of individuals like me and you: auditors and coders who have been providing education to providers for more than 20 years. Prior to the inception of electronic medical records/ electronic health records (EMRs/EHRs), we were reliant on the provider to have a recollection of the documentation requirements each and every time they dictated an encounter, so many of us (not just you, I’m including me as well) in the educational arena thought it best to teach providers to document the most content ever needed, which would enable the support of any level of service based on documentation components only. This didn’t necessarily drive the encounter on the nature of the presenting problem of the patient, which thereby would drive the overall level of medical necessity, because this was not the emphasis of documentation this many years ago.

This over-education and over-documentation in the industry fed the commercialization of the EMR by giving vendors cutting-edge market share when they created software programs with fandangle templates that produced the maximum amount of documentation for each and every encounter. The problem with this is that along the way, the Centers for Medicare & Medicaid Services (CMS) changed the playing field. The 2003 Institute of Medicine Claims Processing Manual indicated that selecting the proper level of E&M service should be performed by producing the documentation that best met the CPT® code descriptor. Contrast this rule to the current guidelines issued in that same manual in our present year, and we find language indicating that our documentation should not be judged by the volume of documentation alone. So, CMS changed the rules along the way. No bulletins, no fancy alerts, no American Medical Association (AMA) CPT guidance indicated this change – but it was a change all the same.

So, in essence, the question changed from “how well did you meet documentation guidelines?” to “can you tell us your thought process and how you determined your assessment and treatment plan for the patient?” Furthermore, you cannot just tell us this for one date of service, or rely on an entire medical record from which you treat the patient from encounter to encounter to help define this plan of care, but you now have to regurgitate that information for every single visit.

How archaic is this process? That is saying:

“Dear Doctor, we are implementing an EMR to assist in continuity of care for your patients, but oh by the way, make sure you document to non-clinicians and therefore spell out your thoughts, your rationale, and the complexities you considered for each and every patient you see, each and every day, and be sure to include all of the probables, rule-outs, and definitive diagnoses or signs/symptoms you can.”

How backward is this? Then we have auditors, coders, compliance professionals, and carriers telling them, “don’t copy and paste either!” And ”oh by the way, we are not paying more for E&M, but we will be auditing them more.” Are you kidding me?

I have officially digressed. I have ventured away from the topic of note bloat. Again, we are to blame: auditors, coders, educators, consultants, compliance professionals, and yes, even the carriers have created an environment in which we have pushed our providers to note bloat. The problem is, that is now old-school. That is the thinking from 2003 and prior encounters, based on previous interpretation of the Claims Processing Manual but not today’s documentation expectations.

Why has the game changed? My personal opinion is that this came about because of the electronic templates within the medical records. CMS has indicated in guidance that its concern regarding electronic documentation is that the templates encourage providers to code higher based on documentation alone, and that documentation guidance for specific levels of service (i.e., the highest-level encounter, level 5) is now easily obtained through these templates. When considering documentation that is created by templates alone, we find that the humanity in the note is nonexistent. We find that documentation is an exercise, a chore, so to speak, in the claim reimbursement process, as opposed to an actual record of the encounter.

My answer for this is that I take ownership – and many of our peers in auditing and coding should as well, for teaching providers to document the maximum possible. We have encouraged providers to always include 4 HPI (history of present illness), 10+ ROS (review of systems), 3 PFSH (past, family, and/or social history), and an 8-point body system exam as a seat belt methodology, but this has been taken over by templates that accomplish this and do not provide individual patient specifics.

As a reverse exercise, think of this: CMS reimburses a whopping $73 (on average) for the average E&M level, which is a 99213, but what we fail to consider is what work CMS deems appropriate for this level and this reimbursement rate. It’s 1 HPI, 1 ROS, 0 PFSH, and two organ systems on exam; therefore, my provider should be able to document the following for a 99213:

CC: Follow up of HTN
HPI: Stable
ROS: No swelling in the extremities
BP: 130/82
Weight: 185 lbs.’
HR: 72 bpm
Cardio: Normal rate and rhythm with no murmur

However, most coders and auditors would review this minimal documentation and push it back to the provider as not enough to support a 99213, because what they really want is 4 HPI, 10+ ROS, and 3 PFSH. Yet if the provider did record this information, many would then indicate that they didn’t need this elaborate workup for a level 3 encounter. So, which is it?

As coders, auditors, educators, and compliance professionals, we cannot continue to speak out of both sides of our mouth with educating in a manner that contradicts the guidelines.

Frank Cohen, director of data analytics for DoctorsManagement, has done the math, and determined that it takes 1,500 decision points to reach the correct level of E&M service. You read that correctly: 1,500 decision points. That means that the provider is more apt to choose the wrong level of service than the wrong dosage of a drug or the wrong therapy for a patient condition, which is good news for us as consumers of healthcare services – but yet the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) says they should be right 95 percent of the time. So is the seat belt methodology really wrong?

What is our goal in healthcare? It should be great patient care leading to great outcomes, but unfortunately, it seems that the focus is more documentation-centric than patient-centric.

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