This article was written by Tony Mira of Anesthesia Business Consultants.
It is a question asked quite often: Is marking a check box on the anesthesia record sufficient documentation? For medical review and for billing purposes?
Check boxes are a very convenient way to document services provided to a patient with minimal time spent dictating or writing out everything that is done. We see check boxes on pre-operative assessments, anesthesia records and evaluation and management service (E&M) forms, just to name a few. Templates increase the efficiency of the clinical documentation, but are they an acceptable form of documentation?
On November 9, 2012, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 438, which provides some insight into CMS’ views on the use of templates in medical record documentation and the risks, as well as some guidance.
In its Transmittal, CMS stated its position on the use of templates and check boxes:
CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/ [Licensed/Certified Medical Professional (“LCMP”)] may choose any template to assist in documenting medical information.
Even though CMS does not prohibit the use of templates, it calls attention to the limitations of incorporating templates into a physician’s record-keeping practices. Specifically, CMS discourages (but does not prohibit) the use of “check box” templates:
Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” preferred answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.
If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them [sic] to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.
Some Medicare carriers have provided guidance regarding using model forms, checklists and/or electronic medical records (EMRs) for efficient documentation. Wisconsin Physician Services (WPS), the Legacy Part B carrier for Illinois, Wisconsin and Minnesota, for instance, offers the following recommendations for using templates, checklists and/or EMRs for documenting evaluation and management services:
Templates and checkboxes may be frowned upon by Medicare, but they are still used widely— perhaps universally—in anesthesia practice. Anesthesia records typically contain checkboxes (or lines for checkmarks and/or initials; initials are critical where different clinicians have performed the checked procedure and the anesthesia service) for the placement of invasive monitoring lines and post-operative pain blocks, and for TEE monitoring. ABC likes forms that include two checkboxes each for Swan-Ganz catheters, arterial lines and central venous pressure lines, one indicating “pre-op” or “pre-OR” and the other “intra-op” or “in-OR” placement. This helps coders to determine whether the time spent placing the line is included in or excluded from the anesthesia time to be reported. As an aside, this alternative-timing checkbox system is a good example of why ABC strongly encourages clients to send us their complete anesthesia records and not just charge slips or billing tickets. We also want to emphasize that this Alert presents some models of the acceptable use of templates. There are certainly others.
It is also extremely common to use a template or pre-printed language that the anesthesiologist can sign to comply with the Medicare requirement (42 C.F.R. § 415.110(3)(b)):
Medical Documentation. The physician alone inclusively documents in the patient’s medical record that the [medical direction] conditions set forth [above] have been satisfied, specifically documenting that he or she performed the pre-anesthetic evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence where applicable.”
Acknowledging that “It is burdensome … and few anesthesiologists find it possible or meaningful to copy the language out by hand,” the ASA Manual on Anesthesia Departmental Organization and Management (the MADOM, © 2010) notes that “Many practices have satisfied themselves by including a compliance section on their anesthesia record requiring the anesthesiologist to sign (or even just initial) a preprinted statement similar to the following:
“I (we) certify that I (we) participated in induction __________________________ emergence______________________, other critical periods,________________________ remained immediately available _______________________, and monitored the patient at frequent intervals __________________, or was (were) present for the entire anesthetic.”
Legibility. It is also worth reminding our readers that the general principle of medical record documentation to support a service billed for payment includes the following:
Medical records should be complete and legible
Medical records should include the legible identity of the provider and the date of service
Acceptable signatures, according to the Medlearn Matters information sheet entitled “Importance of Preparing/Maintaining Legible Medical Record” (MLN Matters® Number: SE1237) include:
With the new year approaching, anesthesiologists, pain physicians and other clinicians utilizing templates, including templates with check boxes, may find this as an opportune time to review their current documentation practices and ensure that they are consistent with the applicable laws, regulations and policies. Moreover, in reviewing templates, you should ensure that all short-hand or time-saving tools are not only comprehensive, but also flexible enough to allow for additional documentation. In addition to reviewing templates, you may also find this as a good opportunity to educate, or re-educate, members of your groups and staff on proper documentation. Understanding that a template is a tool and not the end-all-be-all of the documentation is crucial. It is important to remember: medical documentation must always be accurate, complete and support medical necessity and be backed by a legible signature.
It is a question asked quite often: Is marking a check box on the anesthesia record sufficient documentation? For medical review and for billing purposes?
Check boxes are a very convenient way to document services provided to a patient with minimal time spent dictating or writing out everything that is done. We see check boxes on pre-operative assessments, anesthesia records and evaluation and management service (E&M) forms, just to name a few. Templates increase the efficiency of the clinical documentation, but are they an acceptable form of documentation?
On November 9, 2012, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 438, which provides some insight into CMS’ views on the use of templates in medical record documentation and the risks, as well as some guidance.
In its Transmittal, CMS stated its position on the use of templates and check boxes:
CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/ [Licensed/Certified Medical Professional (“LCMP”)] may choose any template to assist in documenting medical information.
Even though CMS does not prohibit the use of templates, it calls attention to the limitations of incorporating templates into a physician’s record-keeping practices. Specifically, CMS discourages (but does not prohibit) the use of “check box” templates:
Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” preferred answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.
If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them [sic] to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.
Some Medicare carriers have provided guidance regarding using model forms, checklists and/or electronic medical records (EMRs) for efficient documentation. Wisconsin Physician Services (WPS), the Legacy Part B carrier for Illinois, Wisconsin and Minnesota, for instance, offers the following recommendations for using templates, checklists and/or EMRs for documenting evaluation and management services:
- Either the ancillary staff or the patient may complete the Review of Systems (ROS) and the Past Family Social History (PFSH) as part of the template, checklist, and/or electronic medical record. The provider must notate his/her review of the information. Additions to the file or confirming notations substantiate the provider's review.
- The provider may use an ROS or PFSH from a previous encounter. The provider must notate the date of the earlier ROS or PFSH and review all elements of the previous encounter notating any changes or elements not reviewed.
- The billing provider must perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation.
- Documentation must clearly define the examination and findings to support the level of service submitted.
- A brief statement or notation of "negative" or "normal" is sufficient to document normal findings.
- The provider must document any specific and pertinent abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ system(s). A notation of "abnormal" without elaboration is insufficient documentation.
- The provider must describe any abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ(s) systems.
- Please forward a copy of abbreviations or "keys" used in the document if these are other than standard medical abbreviations.
- Providers should be wary of templates that have pre-printed information indicating certain "comprehensive" level services were performed. Documentation for each encounter must be specific to that encounter.
- Signature requirements do not change with the use of templates, checklists, and/or electronic medical records. The documentation must show a legible identifier of the provider.
Templates and checkboxes may be frowned upon by Medicare, but they are still used widely— perhaps universally—in anesthesia practice. Anesthesia records typically contain checkboxes (or lines for checkmarks and/or initials; initials are critical where different clinicians have performed the checked procedure and the anesthesia service) for the placement of invasive monitoring lines and post-operative pain blocks, and for TEE monitoring. ABC likes forms that include two checkboxes each for Swan-Ganz catheters, arterial lines and central venous pressure lines, one indicating “pre-op” or “pre-OR” and the other “intra-op” or “in-OR” placement. This helps coders to determine whether the time spent placing the line is included in or excluded from the anesthesia time to be reported. As an aside, this alternative-timing checkbox system is a good example of why ABC strongly encourages clients to send us their complete anesthesia records and not just charge slips or billing tickets. We also want to emphasize that this Alert presents some models of the acceptable use of templates. There are certainly others.
It is also extremely common to use a template or pre-printed language that the anesthesiologist can sign to comply with the Medicare requirement (42 C.F.R. § 415.110(3)(b)):
Medical Documentation. The physician alone inclusively documents in the patient’s medical record that the [medical direction] conditions set forth [above] have been satisfied, specifically documenting that he or she performed the pre-anesthetic evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence where applicable.”
Acknowledging that “It is burdensome … and few anesthesiologists find it possible or meaningful to copy the language out by hand,” the ASA Manual on Anesthesia Departmental Organization and Management (the MADOM, © 2010) notes that “Many practices have satisfied themselves by including a compliance section on their anesthesia record requiring the anesthesiologist to sign (or even just initial) a preprinted statement similar to the following:
“I (we) certify that I (we) participated in induction __________________________ emergence______________________, other critical periods,________________________ remained immediately available _______________________, and monitored the patient at frequent intervals __________________, or was (were) present for the entire anesthetic.”
Legibility. It is also worth reminding our readers that the general principle of medical record documentation to support a service billed for payment includes the following:
Medical records should be complete and legible
Medical records should include the legible identity of the provider and the date of service
Acceptable signatures, according to the Medlearn Matters information sheet entitled “Importance of Preparing/Maintaining Legible Medical Record” (MLN Matters® Number: SE1237) include:
- Legible full signature
- Legible first initial and last name
- Illegible signature over a typed or printed name
- Initials over a typed or printed name
With the new year approaching, anesthesiologists, pain physicians and other clinicians utilizing templates, including templates with check boxes, may find this as an opportune time to review their current documentation practices and ensure that they are consistent with the applicable laws, regulations and policies. Moreover, in reviewing templates, you should ensure that all short-hand or time-saving tools are not only comprehensive, but also flexible enough to allow for additional documentation. In addition to reviewing templates, you may also find this as a good opportunity to educate, or re-educate, members of your groups and staff on proper documentation. Understanding that a template is a tool and not the end-all-be-all of the documentation is crucial. It is important to remember: medical documentation must always be accurate, complete and support medical necessity and be backed by a legible signature.