Episode 381 - #Terry Tuesday - The Critical Importance of Documentation

All right, hey everybody. Happy September, 2025. It's absolutely pure insanity that we are already now in the ninth month of this year. People weren't joking when I was younger, when they said, wait till you get my age, time flies. And boy, they were not kidding. Well, it's a Tuesday. It's a hashtag, Terry Tuesday day. I am excited because I get to hang out with my good friend, Terry Fletcher after a long, labor day weekend. So hello, my friend. Hello, what was your weekend? You know, it was all work. Yeah, me too. All work. Yeah, I was at the winery all weekend. We were extremely busy, which was a wonderful thing. We had your other work. My other work, which really outside of being a lot of like physical labor, it's actually not work. It's incredibly enjoyable. Okay, even though I don't drink much. Okay. So yeah, it was a great weekend, great labor day. I hope you had a wonderful labor day as well. I hope you and the family got a chance to kick back, relax, chill out in the pool, drink. No, no chance. It was too hot. We basically stayed in and worked. Tom did. Tom went out. My husband, he went out and did a couple things, but I was like, I'm not going out in 100 degrees, but it's better today except for the win storm. We had this this morning, but you know, we're good. So good. Happy to be in September. Yeah, I hear you. All right. So I do want to say, well, anyways, I'll save this for later. Let's go ahead and jump in because I know that you and I were supposed to do this podcast early this morning and because of craziness that I've had going on all day with clients and their attorneys and some other fun stuff. I delayed you, my consultant extraordinaire friend to right now. So let's go ahead and let's jump straight in and tell me what's going on. What's on your mind? Well, since I had all kinds of downtime this weekend as far as not having to deal actively with clients, I got a lot of auditing done, which always brings up fun topics. And one of the trends, I guess I'll see kind of like hula hoops, you know, the trends that I saw in the auditing this weekend was an abundance and not in a good way of macros and smart phrases. And oh my gosh, Sean, talk about a problem. So let me explain a couple of them and happy to have you chime in on this one. So a couple of things that, you know, and doctors adding diagnoses that are an active or appropriate for the patient encounter or they weren't addressed on the claim. So here's one, and I thought this was interesting. So pulmonologist, pulmonary audits. So I was agreeing with the levels of service based on, you know, what was done. And I think sometimes when practices get a green light saying, oh, well, you know what, we build that level four or that level five appropriately, then they think that auditors or payers don't look past that. That's not true. We look at the record and its entirety because we're supposed to. So what I started seeing and it was, it was definitely a trend was a smart phrase and it said on every single patient, I'm going to quote, perform some sort of exercises tolerated, unquote. And then they added the Z code, Z71.82 for exercise counseling. I'm like, that's not counseling. They added it on every single patient and said, hey, if you get a chance to do anything, just try it. Well, then I then I realized that some patients were wheelchair bound. Some patients were incapacitated due to emphysema and deteriorating COPD. Another was declining lung capacity and should limit activity. These are, I mean, so they put that that smart phrase in there and then they add that diagnosis and then they'd actually say in free type, this other stuff. And it's just like, okay, does anybody review their notes? And then there was another one again, pulmonology. That was a hospital audit. So it wasn't the facility itself, but it was in patient services. And they were following patients, for example, that had maybe, um, supolmonary issues or respiratory issues. And they were in there for maybe pneumonia or I saw one that the patient was actually, they only diagnosed UTI. So urinary tract infection. But when I dug deeper, the patient was actually admitted for septic shock that was triggered by the UTI. And I'm just like, you know, the doctors trying to build the highest level of hospital visit in some cases, critical care. And they missed the critical diagnosis. And then, you know, finally, I saw another one coming back to the office. I'm noticing that a lot of providers have kind of started playing the game with HCCs and realizing under their, you know, quality measures that they're going to get maybe reimbursed more for the higher weighted codes that they put in there. So they're seeing a patient, let's say, for CPAP, for sleep apnea compliance. And everything looks good. Everything's fine. No problems. And in prescription for another tube or mask or better fitting mask, that's a low level visit. Patients doing great. It's one stable chronic condition. The, that's not technically a drug management script. It's a low risk for additional treatment because they just put in something for a new mask. So that is a low level visit. But then they put the primary code as breast cancer that another doctor is following. And they seem to forget that page nine of CPT specifically says a notation in the patient's medical record that another professional is managing the problem without additional assessment or care coordination documentation does not qualify as being addressed or managed by the physician or other QHP reporting the service. And I fall back on that a lot because I see a lot of listed high, high, high, high, archi codes or high weighted codes when the encounter itself isn't for that. The patient's coming in for a cold or the patient's again coming in for CPAP compliance. But they're using these. They're using these higher, high-nose agents to get a higher level of service. Yeah, to try and get a level four or five. Well, this is just as bad as what the insurance companies are doing and what you see got a good thing for them to do. Now we know why the insurance companies are doing this because they're seeing the same trends. And I'm not, you know, I'm a physician advocate. But because I also do payer audits, I do see both sides of the coin. And just to extend a little, and I hate to call it grace to payers because we know that they're just in it for their profits. They're not even in it for, you know, they're just the main, just to break even. They're in it for profits. And so I get that. I mean, but the problem is is that, and I think you said this to me one time, you know, if the OIG is looking at it, maybe you should be looking at it in your practice too. Why are they looking at it? Because something triggered it. Well, this is what triggered what Signe is doing, what Blue Cross and Blue Shield of Arkansas is doing. What, you know, some of the other ethnoes are doing as far as automatically, aridmatically, algorithm, just, you know, randomly downcoding because they see the same thing that I'm seeing in regular, just compliance audits and coding audits. And so I think the topic today, I really wanted to bring this forward because you need to code and report what you do, period, end of story, what you do today. If that breast cancer had any impact or, you know, if you had to address it because it was going to have an involvement or a complication or a risk to your management of your patient and you needed to address that along with what meds you prescribed or what treatment you did or the patient had to do something different because of their status of some other diagnoses. Then secondarily, yes, you're allowed to put that in there. But to first put it on there primarily, especially if it's not that type of provider, you know, just to get the upcode is wrong. And so, and it's just, it's opening you up for, what do you call it, invited risk? Yeah, listen, look, I go back to what I always say. And I know prosecutors and defense counsel, if I'm on the plaintiff's side or prosecution side, love to listen to these podcasts because they love to try to find these little sound bites. So I'm going to give you guys a sound bite right now. And I'm going to tell you if you use this during a cross examination, I'm going to say, I remember that and you need to go five minutes before me saying this to hear what Terry Fletcher consultant extraordinaire said and then a minute after my little sound bite. So you can hear what we both say. Listen, providers should be only coding for the services for which they are actively managing during that specific encounter. Now, if there is an HCC code that supports a current diagnosis from another right in HCC of a chronic disease that could play into the treatment modalities being prescribed for today's encounter for today's symptom signs conditions, whatever it may be. And that is complicating the patient's care by all means, COVID HCC. But if it has absolutely nothing to do with what the patient is being seen for today, but they just happen to have some chronic diseases. And now all of a sudden you're throwing those on there to drive a higher level of evaluation and management service resulting in a higher rate of remuneration. Well, that's problematic. That's not good. That's not the way things should be done. No, I agree. And let's put it in. So let me give you an example for the things that where you can actually use those HCCs or those hierarchy codes where it would be appropriate. Let's say you have a patient that needs to have hip surgery, but your provider is an orthopedic surgeon. Well, they're not going to be managing diabetes. But let's say during that, because they are trying to say, well, we want the higher code that's always the level five. Well, isn't really, remember, management, again, you need two out of three, but management, it says elective major surgery without identified patient or procedure risk factors. So it's for that patient. And then the high one is that with identified risk factors for patient and procedure risk factor. Again, it's for that patient. Well, what they're trying to tell us here, and let's break it down a little bit, is let's say the patient is diabetic. Well, as a former RN, I say former, because I'm not practicing. I understand that a patient who has diabetes or who has a comorbidity may be slower to heal, maybe slower to recover from that kind of surgery. And so I get that, but we can't make the leap as an auditor. We can't make the leap as coders. The doctor has to tie that in if that is in fact the case. And if it is, then secondarily, yes, you can report that code by mentioning it within your note, why this is high risk for that patient because of that identified patient risk factor. But if it's just listed, and somebody else is managing it, and you don't tie in, and like it says in CBT, go go back to basics. If it says there, it says, again, without additional assessment. So first of all, we have to see an assessment or care coordination documented. That does not mean it was addressed. And what they're talking about with care coordination documented is, you know, what are you going to have to do as far as pain management with somebody who's a diabetic? What are you going to have to do with home healthcare? What will you have to do with the patient with physical therapy? You know, you're going to have to make those situations clear within the documentation, or it's not a routine risk factors to surgery, that's not going to get it done for you. And so, you know, you really need to look at, and when I say you, I'm talking to listeners, you need to look at the patient as an entire health picture. What is it that you're doing that's impacting what your what is going to happen with that patient? Either once discharged or once left your office and you're saying, you know, when do they need to come back? I see a lot of records right now that are not complete. There's no return to clinic date. Or my favorite is PRN a year. PRN patient return is needed. So now in your risk of complications and morbidity and mortality of patient management, when you say PRN and you tell a patient come back of you feel you need to, the risk has now been transferred to the patient's decision, not the provider. So to try to get a higher level on that, when you're not the one directing care, you know, if you said something like patient needs to return to clinic in three months, so we can monitor X, Y, Z because my concern for, or even if it's six months, why do they need to come back in that capacity? And what is it that you're going to see at that point? So complete documentation is just so important. Don't just assume that, well, if I list three pages of what they've had since 1978, then the, you know, the auditor, the coder is going to know that this patient's a train ride. None necessarily. Maybe they're now recovered. Maybe there's not an issue. But you and I have looked at enough records. And I know you're not an auditor, but I know you have to review records and then have somebody also review them for you and then breathe you on them, where you've seen enough, where I'm sure you're that, well, you're on mute, buddy. But just see that I know that, you know, you're not a formal auditor, let's say, but I know you've seen enough records where I know you've seen something like that and you're going, wait a minute. Where do I find the one paragraph about this patient? Because I've just kind of weeded through four pages of nothing. Yeah, what I was saying while I was muted was, hey, wait a minute. I'm an auditor. I'm just not an auditor extraordinaire like you. You're kind of an auditor. I don't think I look you an auditor. You're a defense operative. Look, I know enough when I look at charts to be able to say, this is good. This is bad or this is really bad. Yeah, or you know, I think I'll call Terry or Stephanie and see what they think. 99% of the time I'm picking up the phone and I'm calling one of the ladies or a starter Paul. You guys probably are better equipped to look at this stuff than me. But here's what I'm saying. What do you think? And why are you bringing up that Terry? Yeah, it's actually, I love it because it actually, I learned so much from all of you guys because I have such a specific mindset when I'm going into something to always try to look for, you know, what did what did an auditor get wrong? That a pair, right? As opposed to like you guys looking at it and saying, hey, the provider just didn't code this correctly or didn't dot not that they didn't code it correctly. That's one thing that they didn't document it well enough. No, I'm on mute. And the other thing, you know, that I see too is, okay, so when I mentioned the smart phrase and then trying to grab a diagnosis where it wasn't a complete link to the patient where it was just every single patient gets the same smart phrase. Try to exercise, try to exercise. You know, I saw one doctor saying that he did lifestyle medicine on every single patient trying to up from a level two to a three when all he said is make sure you eat your green leafy vegetables daily. And I'm like, there was some patients that that was not a good idea because they're on statins. I'm like, you can't tell patients that unless you look at what they're taking. But here's another one. And this is, I know I'm kind of bearing off a little bit, but one is smoking cessation. So I'm seeing the 9 9 406 time-based code on smoking a tobacco use cessation counseling. And it's three to 10 minutes. And I see doctors saying we spent three to 10 minutes. No, you need to say how much time you spent. Do not use CPT wording. That's a guideline, you know, saying that's a prompt. You have to have at least three minutes or up to 10. So I spent six minutes. But one thing that they that I think a lot of people forget on behavioral change interventions. These are for persons who have behavior that's considered an illness illness itself. They may have tobacco use and addiction, substance abuse or misuse. And this can be reported as part of the treatment of the condition related to or potentially exacerbated by the behavior or when the harmful behavior has resulted or even not yet resulted in illness and you have to counsel them. But it's looking at the definition of the code and then reading on further and CMS rules. You know, you first of all, because you're going to need a 25 modifier on your ENM, you know, that's going to trigger something if it's not done right. But you have to show validated interventions. You have to show it says assessing readiness for change and barriers to change. So the patient has to agree to change. I'm seeing a lot of times on, you know, records where it says patient was encouraged to quit smoking. And they try to build this. And they spent three to 10 minutes encouraging patient quit smoking. No, no, no, the patient agreed to, you know, agreed to now attempt to stop smoking. The interventions we gave them is, you know, Nicarite gum. We also are providing them with, you know, motivational counseling. We're arranging for follow-up services to, you know, different sites. You know, there's all kinds of different things they can do. And it was interesting that, you know, a doctor actually wanted to argue with me about this until I brought them their information. They went, I've actually never read the code. It was just brought to me that I could build it if I mentioned smoking unlike. Come on. Come on. I know. See, this is the kind of crap that makes our lives so difficult, right? Well, it keeps us in business. That's for sure. I'm never going to get to retires on either of you. It definitely keeps us in business. But I mean, you know, my point is this. You know what? I'm not even gonna say it. I'm just gonna leave it at that. You're right. It's this kind of behavior that allows you and I to put food on the table for a thing. - Yeah, it's just, you know, it's sad. What's I mean to myself? It's sad because I really, I believe the doctors and the providers are really trying to do it right. I do, otherwise I wouldn't be in the business. And I think, you know, 98% of providers are doing, are trying to do it correctly. Unfortunately, we have that 2% and the 2% is they're trying to do anything they can to get another line item. You know, add 15 diagnoses. They think that's gonna beef it up or add six pages of something where you and I, it even says in the documentation rules, you know, it's not the volume. It's a substantive work that's there. And you have to shy away from that. You know, you need to document what it is you're doing. I know that it's tough because a lot of doctors are like, yeah, but you're trying to get us to document more when, you know, we're trying to document less or use AI or, you know, get out of all this paperwork. Well, when AMA came out with the new rules in 2021 and then updated them with the hospital included in 2023, I noticed a couple of things. First of all, AMA, they were living in La La land because they basically said patients over paperwork, we're now gonna make it streamlined for providers, we're not gonna require them to deal with the history and exam as far as scoring. You still have to have a medically indicated, you know, that's still required, but it's what you think it should be so it can just be focused on that problem. But they did it and they even set it in these, you know, the AMACBT update so that you can spend more time with patients. Well, that's not what's happened. Now instead of two patients an hour or four patients in an hour, if it's established, I'm now seeing doctors squeezing in six patients and it's established in an hour or four patients that are new in an hour and trying to build still the higher levels of code. And it was supposed to be so that you can take a breath. So the patients feel like you're engaged so that you can actually still make what you were making but not have to deal with the administrative burden. But instead, it's now, you've kind of used it against yourself where you're saying, okay, I don't wanna have to do all this but now I can fit more patients in. And it's just like the more money you make, the more you spend. You know, you have to look at it for what it was and take a step back a minute and realize that, you know, the smart phrases, EMRs, AI, they're not perfect. They don't have sometimes logic, they can't, they don't have medical decision making as a rule that you do. And they don't know the patient in front of you's history. Only what's on paper. And so if you have incomplete documentation or if you aren't giving the nuance of your visit or doing any free type at all that explains this particular patient, you know, then you're gonna have a problem. Maybe today that patient was upset 'cause they had a death in the family and that's the reason for her blood pressure increase today. But she's been on medication that's been fine. Well, unless that's documented, that's, you know, that's not something you can infer from, you know, IT. So I just wanted to just bring this up because smart phrases, macros, lack of documentation and then overutilization of codes that are not relevant or without purpose is just gonna invite risk. That's all I'm gonna say on that. 100% and inviting risk means that you're inviting the potential of a prosecutor looking to indict you under the false claims act. Listen, if you've not realized it at this point, the current administration for good reason has taken an absolute sledgehammer to the healthcare industry to fight fraud, waste, and abuse. The number of TPE audits, the number of smirks, the number of certs, the number of racks, max, U-picks. All of these entities that have investigational authority, audit authority, they're on high alert. They are taking this stuff to the max. You've got to listen to the guidance that Terry Fletcher is giving you on these #Terry Tuesdays with respect to getting the CPT codes, the diagnosis codes, the HCCs, the modifiers, the requirements for documentation, you've got to get these things right. - And in saying that Sean, I wanted to kind of tease for our next episode, I think we need to revisit the shared visits 'cause they're a mess right now. - They are, they are mess, they are mess. All right, so that's gonna wrap up this episode of the Compliance Guy, our #TerryTuesday. I do wanna ask everybody to please, please, please, please, take a look at the article I published today, September 2nd. It's on prosecutorial misconduct, a focus on the False Claims Act violations, and the case of United States, the Elizabeth Mercedes Hernandez, where I dissect different aspects of the 2023 case involving this healthcare provider who is charged with a False Claims Act violation and highlighting procedural irregularities and potential overreach that could undermine justice or her OIG guidelines. I talk about my engagement with the president of the United States with other members of his senior cabinet, what we are doing right now with respect to her clemency and my efforts on a pardon for Elizabeth. I'm begging you guys to please read this critical article, go to change.org. Look up Elizabeth Mercedes Hernandez case. If you in your heart feel compelled to sign this petition, please do. I have more than, I have at, right at or just above 200 hours of my personal time into this case with no money being paid to me because the evidence and everything that I have reviewed points to this woman's innocence, I've spoken to other prosecutors who have looked at this. I am talking now to other people involved that want this woman home with her five children because that's where she belongs. So please, I'm begging you, go read this article, click on the link and sign the petition. All right, that's going to do it for this hashtag carry Tuesday episode on the compliance guy. Terry did a great job of her teaser for next week's episode where we're going to once again explore the shared visits because she's right. It's a mess. All right, I'll be back later this week with a gentleman who I've been trying for the last few weeks to get a podcast on the books for, but we've just had no luck because of one problem after another mainly my problems. So until then, remember be good to your son's book more importantly, yeah, be good to each other. Take care.