In the struggle to comply with Medicare's complex, changing billing rules, your patient examination forms are most likely your Achilles' heel. This is especially true should you happen to be the target of an audit.

The government's requirements are extensive for documenting history taking, examination findings and medical decision making and interpretation. And subspecialists aren't exempt from fulfilling all the requirements when they're billing higher level codes. Many types of exam forms are used in practices across the country. But the ones you use should make the documentation of the services you provide as effortless -- and complete -- as possible. The secret to accomplishing those objectives is using preprinted (forced entry) examination forms, designed to accommodate minimum description while still facilitating compliance.

In this article, I'll review Medicare's basic requirements and how you should be thinking of them in terms of your exam forms. Once you've considered the requirements in that context, I'll explain how they should be reflected on your forms.

Narratives, inventories and elements

All examination forms should address the three key components of Medicare's documentation guidelines -- history, examination and medical decision making:

�        History. The Chief Complaint and History of Present Illness are narrative. The Review of Systems and Past Family Social History are inventories; negatives as well as positives must be noted. Abnormalities must be described.

�        Examination. 14 elements comprise a comprehensive examination in Evaluation and Management (E/M) coding. Many carriers have policies for the Ophthalmology Codes that enumerate the elements. Negative as well as positive findings must be noted. Abnormalities must be described.
You must address each element; however, you don't have to describe the component of each element unless you detect an abnormality.

�        Medical decision making. All existing as well as possible, probable and rule-out diagnoses should be listed. Orders for diagnostic tests must be documented. You must document your consultations with other practitioners, whether they're intraoffice or interoffice. The Impression and Plan aspect of the examination is narrative.

What you need to change

For compliance and convenience, your exam forms should reflect those requirements in the following manner:

�        For narratives. Make sure you allot adequate space for description. Lines to write on are better than empty spaces. If you leave yourself empty spaces in these sections, you're tempted to write sloppily or in the wrong place, ending up with notes that are difficult or impossible for claims checkers to follow.

�        For inventories. Use check-off boxes for negatives and positives. Leave enough room for description of abnormalities.

�        For elements. Set up each element so that you can check it off as normal or abnormal. Leave room for description of abnormalities. (Normal components of the elements don't have to be described.) Don't forget that dilating drops -- name, dosage and in which eye they're administered -- must be on the chart as well.
Also, column design comes into play with elements. I recommend a two-column design, which lists elements for each eye in one column and leaves space to write off to the side. This promotes much better documentation than a center-column design, which lists the elements in the center column and leaves you with the option of writing on either side.

�        Orders. Your exam forms should also make documenting your management of patients simple. For example, you should include check boxes for diagnostic tests you might order and to indicate that you instructed the patient to return to your office, or that you've written a letter to a practitioner that you're consulting with or who will also be seeing the patient. Check boxes prevent you from having to write out that you've taken care of these aspects of the exam.

Time for a checkup

Incorporating the design options described above into your patient examination forms ensures that payers understand exactly what was done in your exam room so that they can pay you accordingly. They'll also minimize the likelihood of a problem should Medicare audit your documentation.

Take a close look at your forms. You'll most likely find that it's high time to revamp them, especially in light of the government's stepped-up anti-fraud initiatives.

Auditing in Overdrive

Why the intensified effort to audit your medical records? One reason is that Medicare itself is subject to audit and was found to have improperly paid $3.2 billion to physicians in 1998. That amount decreased to $3 billion in 1999. As you can see, most of the problems were related to chart documentation, which is a function of exam form design:

This decrease to $3 billion wasn't enough of an impact for federal regulators, however, so the effort to audit providers intensified. This year, President Clinton announced increased funding for Medicare audit efforts. And the pressure will continue: The 2001 budget request for the Medicare Integrity Program (i.e., fraud and abuse) is $680 million.

Riva Lee Asbell is president of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm in Philadelphia. She writes and lectures extensively on coding and compliance issues and has created instructional materials and forms, which are available by calling (215) 629-9221.