Updated on: March 17, 2016

Documentation Remains Crucial Issue Among Physicians

Original story posted on: April 2, 2012

Physician documentation remains a crucial issue among physicians and payers alike, according to panelists appearing on “Live from AAPC” during the 20th national conference of the AAPC going on this week in Las Vegas.


Bringing the issue into sharp focus was J. Paul Spencer, director of compliance for Fi-Med Management, Inc. Appearing during the 60-minute broadcast, Spencer noted that the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) has listed clinical documentation in the 2012 OIG Work Plan.

“For the first time, the OIG has stated that it has seen patterns of similarities for multiple patients of the same physician practice,” Spencer said. “The red flag to the OIG is the looming question, ‘Are the physicians honestly performing the service, or they cutting and pasting documentation elements from previous visits?’”

Expressing similar concerns was Stephen Spain, MD, who spoke about evaluation and management auditing taking place among physicians. Spain discussed some of the recent CMS changes that are affecting E/M codes.

Drilling down on documentation codes was Lynn Myers, MD, who spoke to the issue of documenting Hierarchical Condition Category (HCC) codes. Myers noted that, generally speaking, the more specific the code, the better physicians reflect the acuity of their patients.

Myers cited as an example a patient with diabetes, retinopathy and nephropathy, pointing out that such a patient typically will demand more resources to treat than a patient with only diabetes.

Opening today’s session was the chairman and CEO for AAPC, Reed Pew, who acknowledged that the 2012 conference is the largest ever convened by the association.

The AAPC conference continues through Wednesday.

Register online to listen to our live broadcasts.

Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.