Physicians Who Don't Do Assessments

Nurses Safety

Published

I am writing this somewhat heavy-hearted because what I felt needed to be done did not feel good, but needed to be said... If anyone can relate, I'd love to hear from you.

Recently, a patient I cared for passed away and I feel this death may have been preventable, or at least foreseen. An unfortunate series of events occurred with abnormals reported to the physician and a very non-aggressive approach was taken. This was the last straw for me and the action I've taken since is not a retaliatory effort.

I have noticed this physician write "notes" documenting the heart and lungs were auscultated in his patients, but while present in the room, I've never witnessed the stethoscope touch the patient. This is not the case with ALL the patients, just some. This doctor does not communicate much with nursing staff and disregards information others might find critical and gives no explanation so...I find myself referring to his notes to help piece together his idea of the presenting patient's clinical picture. After doing so, I've realized he has documented an assessment he did not do. I reported this.

As much as I think the physician is a nice guy and pleasant enough, that is no excuse for skimping on patient care. It's difficult to hear patients tell me "I just love Dr. So-and-So. He is just wonderful!" And while he can be, what he does from time to time, is not wonderful - it's dangerous. I can't shake what I know goes on on my side of the bed from my head.

Maybe it is a lie from the enemy to make me feel guilty about my decision to report this doctor. It's just unfortunate that while this greatly respected man goes about his business, I feel I have stabbed him in the back. However, I know, in reality, no one makes him practice the way he does. I almost wish I didn't know what I do so that it can stop eating at me.

Has anyone come across this issue or something similar? This is extremely sensitive and unethical and I realize, a very serious accusation. However, I can not ignore it.

:down: -- Torn

Specializes in Critical Care.

I'm certainly not arguing that any of the practices I'm familiar with are borderline fraud however.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

That first link is not from Medicare or CMS. That's bad advice from a so called billing expert. You can never take CMS rules that literally. CPT code 99231 requires 2 items from either History, Exam, or Decision Making. The Exam itself only requires one organ system to meet the code. Yes, V/S are part of constitutional findings and may be considered one of the organ systems. But that's a simplistic way of looking at E&M.

You have to remember that E&M is medical decision making. How can a provider say with a straight face that he/she arrived at a care plan decision on a patient admitted to a hospital based on vital signs alone? You have to use common sense and your progress note has to make sense. Can you imagine defending your progress note to CMS (or worse, litigation) and all you had to back your medical decision making up is the patient's V/S?

I am not sure I've even seen any provider write a note the way that source is alleging. And as far as I can remember (NP school and all the hospitals I've had privileges in) we were always told to never write the minimum required in our notes.

BTW, your second link (though a CMS source) does not say that writing vital signs alone is sufficient for supporting exam findings in a focused physical exam.

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Specializes in Critical Care.

BTW, your second link (though a CMS source) does not say that writing vital signs alone is sufficient for supporting exam findings in a focused physical exam.

Page 52. One organ system is required, and 3 vitals is sufficient to qualify as one organ system (constitutional). Could/should a provider do more than that? Absolutely. Are they required to by the rules? No.

And yes, I have seen this done.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Page 52. One organ system is required, and 3 vitals is sufficient to qualify as one organ system (constitutional). Could/should a provider do more than that? Absolutely. Are they required to by the rules? No.

And yes, I have seen this done.

OK, that is how a non-provider will interpret that rule. Yes Constitutional is an organ system and 3 vital signs are sufficient to meet this organ system. However, the rule says the provider should use 1 or more organ systems to meet this CPT code. You can't get by using one organ system and calling it good. Just look at the examples your website was using:

On a SOAP note:

#1

S - No pain

O - 120/80, 80, Tmax 98.9

A - no entry

P - no entry

#2

S - no entry

O - 120/80, 80, Tm 98.6

A - HTN - stable

DM - stable

COPD - stable

P - no entry

So your guys think that this note is sufficient. Yes by billing rule, it meets CPT code 99231, the lowest reimbursement one can get for subsequent care in a hospital setting. But does this note tell a CMS reviewer why this patient is even in the hospital? what was being done as far as plan of care? What pertinent findings support the reason why this patient is even in the hospital? If you're telling me that providers in your hospital are writing these kinds of notes, I'm surprised CMS is not fining your institution for keeping patients hospitalized for no real reason.

This is what happens when billers and coders who are not providers are interpreting CMS rules. They only see money value attached to progress notes. This is not how a provider writes notes. First of all, the only rare instance CPT Code 99231 would apply to a real patient situation is when it is a completely stable patient who is ready for discharge. Even then, you wouldn't write such a sloppy note. You would want to cover all bases and add another organ system or two (remember 1 or more organ system is the rule) to clarify that these were checked and indeed the patient is stable.

In your second link (the CMS handbook), there are templates for focused progress notes (starting on page 57). For a Cardiovascular Focused Exam, the organ systems one should include (1 or more) are Constitutional, Respiratory, Cardiovascular, GI, and Neuro (they are highlighted and that's how you know). Sure your biller will tell you that just using Constitutional is enough. But do you see why CMS is giving you these suggestions to include in your note? In fact, if you look at all those templates, there is not a single template where only Constitutional is highlighted. Why? because that organ system by itself will not meet the logic in any note you could ever write on a patient.

I don't know if your providers are writing CPT 99231 all the time on patients. If they are (1) your patients have no business being in a hospital because they are well, (2) your providers are not accurately capturing the level of patient complexity and are being reimbursed for lower rates either because of laziness or are providing substandard care. Can you imagine how much revenue loss that amounts to?

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Specializes in Critical Care.
OK, that is how a non-provider will interpret that rule. Yes Constitutional is an organ system and 3 vital signs are sufficient to meet this organ system. However, the rule says the provider should use 1 or more organ systems to meet this CPT code. You can't get by using one organ system and calling it good.

"1 or more" organ system includes 1 organ system. "More than 1" organ system would require more than one.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.
"1 or more" organ system includes 1 organ system. "More than 1" organ system would require more than one.

You're missing my point. You are arguing that just using Constitutional is sufficient since that meets one organ system if you write 3 Vital Signs. That is true in the sense that it constitutes one organ system. However, nowhere in the CMS link does it say that one can use this organ system alone and it is sufficient. Your link from a coder says that. In real life, Constitutional alone does not support any presenting diagnosis for any patient that is admitted in the hospital.

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Specializes in Critical Care.

As you pointed out, "consitutional" is considered an organ system, one organ system is one, as in less than 2. Page 52, definition of "constitutional" organ assessment:

"Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and

regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be

measured and recorded by ancillary staff) "

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Specializes in Pediatrics, Emergency, Trauma.
OK that is how a non-provider will interpret that rule. Yes Constitutional is an organ system and 3 vital signs are sufficient to meet this organ system. However, the rule says the provider should use 1 or more organ systems to meet this CPT code. You can't get by using one organ system and calling it good. Just look at the examples your website was using: On a SOAP note: #1 S - No pain O - 120/80, 80, Tmax 98.9 A - no entry P - no entry #2 S - no entry O - 120/80, 80, Tm 98.6 A - HTN - stable DM - stable COPD - stable P - no entry So your guys think that this note is sufficient. Yes by billing rule, it meets CPT code 99231, the lowest reimbursement one can get for subsequent care in a hospital setting. But does this note tell a CMS reviewer why this patient is even in the hospital? what was being done as far as plan of care? What pertinent findings support the reason why this patient is even in the hospital? If you're telling me that providers in your hospital are writing these kinds of notes, I'm surprised CMS is not fining your institution for keeping patients hospitalized for no real reason. This is what happens when billers and coders who are not providers are interpreting CMS rules. They only see money value attached to progress notes. This is not how a provider writes notes. First of all, the only rare instance CPT Code 99231 would apply to a real patient situation is when it is a completely stable patient who is ready for discharge. Even then, you wouldn't write such a sloppy note. You would want to cover all bases and add another organ system or two (remember 1 or more organ system is the rule) to clarify that these were checked and indeed the patient is stable. In your second link (the CMS handbook), there are templates for focused progress notes (starting on page 57). For a Cardiovascular Focused Exam, the organ systems one should include (1 or more) are Constitutional, Respiratory, Cardiovascular, GI, and Neuro (they are highlighted and that's how you know). Sure your biller will tell you that just using Constitutional is enough. But do you see why CMS is giving you these suggestions to include in your note? In fact, if you look at all those templates, there is not a single template where only Constitutional is highlighted. Why? because that organ system by itself will not meet the logic in any note you could ever write on a patient. I don't know if your providers are writing CPT 99231 all the time on patients. If they are (1) your patients have no business being in a hospital because they are well, (2) your providers are not accurately capturing the level of patient complexity and are being reimbursed for lower rates either because of laziness or are providing substandard care. Can you imagine how much revenue loss that amounts to?[/quote']

THIS...

I've had as a CMS reviewer bill for the lowest amount due to the exact points Juan pointed out. :yes:

To the OP, I think that your decision to speak up was valid if the doctor is not assessing patients and there were serious issues that occurred as a result; there's one thing trusting clinicans and other providers, but an objective assessment always needs to be made. :yes:

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Specializes in Critical Care.
THIS...

I've had as a CMS reviewer bill for the lowest amount due to the exact points Juan pointed out. :yes:

To the OP, I think that your decision to speak up was valid if the doctor is not assessing patients and there were serious issues that occurred as a result; there's one thing trusting clinicans and other providers, but an objective assessment always needs to be made. :yes:

99231 is the lowest level of follow up codes, so by definition it would bill for the lowest amount, that doesn't mean you can't bill for it at all.

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Specializes in Pediatrics, Emergency, Trauma.
99231 is the lowest level of follow up codes so by definition it would bill for the lowest amount, that doesn't mean you can't bill for it at all.[/quote']

Some things are not getting covered anymore, or even at a lower rate than before; CMS and ICD-9/10 coding are categorized differently; to be clear; a specific ICD-9/10 may be introduced for billing, but if the documentation is not fitting into the specific CMS category that is applicable to the documentation; it's not getting covered; the lists are getting MUCH more shorter in terms of what is covered through CMS, more specifically, Medicare, and you know the adage of if it isn't documented... Juan is very on point with his example of how the code doesn't drive the reimbursement anymore; it's dependent on documentation. :yes:

The more pressing point here is the OP's assertion that there was a missed assessment by a physician, and there was a serious miss.

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Specializes in Critical Care.

The documentation that's required is pretty well defined, can you cite a source to say the specifically required documentation is no longer what's required? As far as I know, CMS is the best source for CMS requirements, and CMS is pretty clear on what's required.

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Specializes in Pediatrics, Emergency, Trauma.
The documentation that's required is pretty well defined can you cite a source to say the specifically required documentation is no longer what's required? As far as I know, CMS is the best source for CMS requirements, and CMS is pretty clear on what's required.[/quote']

I will try to find a source, however, this is informational policy from my work with a CMS contractor, as well as information from the organization that I work with in regards to how CMS handles what they cover. Those policies may not be available to the lay person.

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