Feb 8, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Medical documentation—a topic beloved by many retina practice managers!
Not.
Documentation often fails to enter the conversation until it's on a negative note—think claim denials, recoupments, and audits. Some of us wait until there's a problem to address documentation issues at our retina practices.
You may not be psyched about a medical documentation discussion if you're reading this. But you've also probably encountered some documentation challenges at your retina clinic.
So, let's not waste any time and talk practically about how you can improve it.
You may be surprised by some of the tangible advice we cover!
Remember how I said, "Let's not waste any time?" (Two sentences ago.) Then, why are we defining medical documentation?
Before any clarifying dialogue, it's essential to define your terms.
Medical documentation includes all medical records, including electronic health records (EHRs), lab results, imaging, written notes, and anything regarding a patient's medical experience that can be documented.
For the sake of this article, we're focusing on the notes for each patient visit contained in the patient chart because that's where most errors occur.
The Department of Health and Human Services Office of Inspector General conducted a study on vulnerabilities created by EHRs in January 2014.1 They found two ways EHRs can facilitate errors and fraud:
"Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location.² When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient's medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims."
"Overdocumentation. Overdocumentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.3"
In my decades of experience in the medical industry—more recently in ophthalmology and retina—I've seen documentation errors of all kinds. Many of these errors stemmed from cloned documentation.
I've seen retina patient charts listing an eye with a cataract under 'Lens.' However, the patient had cataract surgery weeks (or months) ago. I've seen charts list conflicting diagnoses, such as the diagnosis codes for proliferative diabetic retinopathy (PDR) with and without edema in the same eye.
EHRs can get wild.
Overdocumentation isn't usually intentional and is often the result of cloned documentation—the retina physician's scribe pulled forward the previous office visit and merely added new information without updating the old.
Here are a few other common medical documentation errors I've seen:
With all of these errors muddling medical documentation, how can it be improved?
Take a proactive approach. Best practices include:
There are many reasons to improve medical documentation at your retina clinic. I mentioned claim denials, recoupments, audits, legal, regulatory, and payer documentation requirements, fraudulent charges, and fines.
Your insurance claims may be denied if your medical documentation doesn't support your coding and billing. If a payer accepts your claim but later determines it's unsupported after reviewing the chart information, you'll have recoupments, whether the payer takes it or you write a check.
If the chart entry was incomplete or incorrect, you could amend the chart documentation and submit an appeal with the corrected documentation. However, there are rules to follow when amending a chart. But that is a topic for another day.
Accurate medical documentation is also vital for patient care and safety, preventing medical errors extending beyond your retina clinic to other practices referencing your patient's documentation. Not to mention, the medical record is a legal document.
Improving the medical documentation at your retina clinic won't happen overnight. Still, there are best practices you can follow to right your ship.
Continuing education and regular, planned audits are two of the most valuable practices.
Keeping the 'how and why' of good documentation top-of-mind with your team can go a long way to reinforce good habits and accountability. Additionally, routine audits can provide helpful feedback for coding and documentation issues.
If you're looking for a second set of eyes to review your documentation—which is recommended to catch errors you might miss—I offer a coding & documentation audit. With decades in the medical industry, a focus on practice management, and a specialty in retina, I have a keen eye for the types of errors you're likely encountering. Schedule a free consultation with me here.
I wish you the best in your battle against poor documentation!
1Levinson, Daniel R. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Department of Health and Human Services Office of Inspector General. 2014; OEI-01-11-00571: 2-3.
2Association of American Medical Colleges, Compliance Officers' Forum. Appropriate Documentation in an EHR: Use of Information That Is Not Generated During the Encounter for Which the Claim Is Submitted: Copying/Importing/Scripts/Templates. July 11, 2001.
3Dougherty, Michelle. HIT Policy Committee Hearing on Clinical Documentation, February 13, 2013. Accessed at http://www.healthit.gov on March 19, 2013.
.png)
