Why do physicians so frequently complain that the tasks of creating consistently compliant (2) documentation and coding are confusing, challenging, and/or unrelated to their goals for medical practice? It is far easier to learn how to identify the precise procedure and diagnostic codes for excision of a benign neoplasm of the lateral lobe of a parotid gland with dissection and preservation of the facial nerve (CPT code 42145 and ICD-9 code 201.2) than it is to master the surgical technique required to perform that challenging operation safely and well. Similarly, with a relatively small amount of training combined with compliantly designed (and physician-friendly) medical record forms, it is far easier to perform and document the medically indicated level of care for a new patient with probable Meniere’s disease (CPT code 99204 and ICD-9 code 386.01) than it is to master the optimal evaluation and management pathways for each patient who presents with significant vertigo.

This author believes there are three factors creating barriers to logically and naturally incorporating precise documentation and accurate coding into optimal medical workflow and patient care excellence:

All three of these deficiencies could, and should, be remedied by introducing effective curricula and documentation tools at the appropriate junctures during medical education. For example, effective documentation of a comprehensive history and physical examination (the “H&P”) is traditionally taught as the first medical school course in clinical medicine, and this meaningful clinical documentation almost exactly parallels the compliant H&P required for evaluation and management (E/M) documentation and coding. This would be an optimal time to introduce sophisticated documentation tools to help young physicians provide and document the desired level of care compliantly. Use of such tools would also allow students to achieve good care far more efficiently than the “time-honored” approach of documenting with only a blank sheet of paper and a pen. As almost all physicians have experienced, performing and documenting a comprehensive H&P with such primitive technology requires between 45 and 90 minutes per patient encounter; this is the medical record equivalent of training students to examine the tympanic membrane using nothing more advanced than direct vision with an open ear speculum or to auscultate the heart by placing their ear directly against the patient’s chest.

The demands of our current medical environment require practicing physicians, academic physicians, residents, and even medical students to complete patient encounters within 10 to 20 minutes. Unfortunately, failure to provide sophisticated documentation tools that facilitate performing and documenting extensive care within this time frame has forced student physicians (and now their professional supervisors and role models) to abandon the high-quality history taking and physical examination they were taught to perform. As a consequence, most physicians currently provide and record only “problem-focused” patient care, which creates compliance problems for their evaluation and management services. The current transformation to EHRs offers a welcome window of opportunity to provide such tools, but unfortunately most current EHR data entry designs have failed to facilitate the recording of individualized (patient-specific and visit-specific) documentation that “meet all of the optimal standards that physicians should apply to introduction of any medical record technology… usability, efficiency, E/M compliance, promotion of individualized quality care, and data integrity” (3). In the optimal documentation and coding model presented here, medical students would receive medical record tools and instruction that together facilitate their ability to provide the comprehensive (and compliant) H&P taught during their early clinical training. This monitoring and mentoring of patient care and documentation should continue throughout residency training as well. In addition, it appears reasonable and logical that, at the onset of residency training, effective and compliant documentation templates should be introduced for recording diagnostic and therapeutic procedures, helping residents develop, practice,
and thereby maintain effective procedure documentation techniques from the outset.

Finally, the beginning of residency training would also be an optimal time to introduce the fundamental concepts of coding for procedures (CPT coding) and diagnoses (ICD-9 coding, soon-to-be replaced by ICD-10 coding). These alphanumeric codes provide a shorthand “language” for recording and reporting the care physicians provide. Just as early childhood is the most successful learning time frame for introducing an individual to a new language, incorporating coding as a parallel language early in residency will enable young physicians to speak this language fluently.

Unfortunately, our medical training programs do not currently provide this idealized approach to incorporating effective documentation and coding skills and tools as an integral component of learning medical care excellence. Instead, upon completing residency training, most physicians are plunged unprepared into the chilling waters of creating documentation that must meet regulatory demands for coding and billing, performance measures, medicolegal protection, and compliance reviews. This current reality calls for an explanation of documentation and coding that can make these principles understandable and workable for practicing and academic physicians, for residents, and even for medical students.

The remainder of this chapter is devoted to presenting the basic principles of each component of coding and documentation and examining their interplay with the current payment system in the United States. This includes examples of structured documentation tools capable of incorporating these principles into the normal workflow of quality patient care, and it underscores the basic tenet that proper coding and documentation must accurately report the care provided, not distort that care to meet external regulatory demands.

Hippocrates probably documented his patient care by writing freehand on parchment with a quill pen. As his patient volume increased with his widening fame, he probably began to experience the time limitations of creating accurate records using such limited technology. Yet over the next several thousand years, the only significant technologic advances for improving medical documentation were the introduction of milled paper and the ballpoint pen. With mounting time pressures, many physicians increased their writing speed by becoming less and less legible, some even attaining a level of illegibility that left them unable to read their own notes. A significant alternative for recording care finally appeared in the 20th century in the form of dictation. This offered physicians an option that was definitely legible and could also be faster than writing an entire record in longhand. In addition, however, it added the often-significant cost of transcribing the dictated records into paper documents.

Whether created by handwriting or dictation, the final medical records were stored as paper documents, which have inherent limitations in ease of access and costs of storing, retrieving, and sharing the records, as well as mining them for data. The heralded introduction of EHRs offers solutions to these information storage and retrieval problems, but it has also introduced a broad spectrum of challenges to effective data entry. Early on, physicians adopting EHRs were required to type their medical observations into the software programs, a process that is not only usually slower than either dictation or writing but also creates barriers to good patient-physician interaction (or alternatively leads to the double effort of physicians writing notes to themselves on paper, which they then use to type their notes at the end of the day, long after seeing their patients; this is a suboptimal and perhaps noncompliant solution to the data entry challenge). Eventually, some electronic records introduced full or partial dictation alternatives, but many have also introduced a variety of automated data entry shortcuts by copying and pasting blocks of text from previous records and/or from preloaded generic descriptions. While speeding the process of documenting a patient encounter, these shortcuts severely curtail individualized documentation, introducing significant problems with compliance (8,9,10) and challenges in understanding what was actually performed (and why it was performed) during each encounter. Fortunately, effective data entry solutions are achievable, and these are also able to provide documentation that is accurate, individualized, and efficient. Physicians should therefore establish criteria that the data entry features of EHR systems must meet to ensure usability, efficiency, compliance, data integrity, and promoting quality care.

Whereas the principles and practice of physicians accurately documenting their patient care have been evolving since Hippocrates saw his first patient, the concept of “codifying” that patient care is a relatively recent phenomenon. It was not until the 1980s that Medicare and most insurers began requiring that physicians submit their claims for payment using CPT procedure codes and ICD diagnostic codes. Prior to that time, physicians submitted most insurance forms with a freetext description of the procedure performed (e.g., “tonsillectomy and adenoidectomy”) and the accompanying diagnosis (e.g., “chronic tonsillitis”). Following the transition to payments based on coding, the purpose of which “is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services” (16), practices have been required to select the most appropriate CPT procedure code (e.g., 42820, for tonsillectomy and adenoidectomy, younger than age 12) and the most appropriate ICD diagnosis code (e.g., 474.02, for chronic tonsillitis and adenoiditis).

Although physician practices and hospitals view procedure and diagnosis coding almost exclusively through the lens of its role in reporting claims for proper payment, these codes also play additional roles in improving health care. CPT advises that its procedure code functions extend to “the development of guidelines for medical care review… to medical education and outcomes, health services, and quality research by providing a useful basis for local, regional, and national utilization comparisons” (16). ICD-9-CM codes are a United States “clinical modification” of the World Health Organization’s International Classification of Disease. Its published intent is “to serve as a useful tool to classify morbidity data for indexing medical records, medical care review, and ambulatory and other medical care programs, as well as for basic health statistics” (17). These functions provide the foundation for some of the goals for system-wide use of EHRs, which are intended to facilitate the collection of coded information about symptoms and diseases, including the relative success of various procedures used to diagnose and treat them.

While these coding benefits promise to advance medical science and improve population health, the primary impact of coding on practicing U.S. physicians is accurate submission of claims to obtain correct payment in a timely manner. Reliable coding for payment depends on accurate documentation, and these demands will increase with the greater coding specificity being introduced in 2014 with the transition to ICD-10 diagnostic codes.

These three documentation principles can be used as cornerstones for medical record designs that meet all of physicians’ requirements for effective documentation and coding tools: