I love your candor on this subject. Obviously you are not yet  completely cynical  about  the documentation issues.  I recently was asked to sign a statement explaining that if I documented "in  error" as to diagnosis codes I could be subject to "criminal" sanctions.

Jail time? I guess so. I did not go in to medicine expecting to risk incarceration for practicing my trade. Malpractice    explorations, yes. Criminal sanctions,not so much.

You may be aware that a hospital progress note in the chart is not satisfactory for documentation purposes unless it is "legible". Therefore any note not legible  and billed for is fraud. In my experience at least 80% of notes are not completely legible. Some completely illegible. I explained the issue to our CFO   and reminded  him that over  400 years ago some guy actually invented a thing called the printing press and that nowadays  most   important communication is  being done with a newfagled thing called a TYPEWRITER or,wonder of wonders , a Computor.

 I once  worked at a tiny hospital on the coast of South Carolina where all progess notes were typed. What a dream to understand what the others involved were doing and thinking. Our CFO thought my suggestion was   "not needed"at this time. "You just need to write legibly".

Some modern doctors finesse the  ROS questions by listing  ten  negative elements and preface  the list by stating that the patient "did not complain about..." ( they were  never asked,of course). Seems to work for them. They  get  the IT person to set up their computor so that they just push a button  and they are in full compliance .

The element I  find most interesting in documentation is family history. Honestly, I have been asking  family  history questions for over 40 years and NEVER has the answer made any difference. I mean if a guy comes in  with chest pain  and a scary looking EKG   and his family history  is negative..... well, in that case, I guess we should just  send him out the door with some Maalox. right? If anything, familty  history contributes to confirmation bias. SO I try to ignore it.

 The only good thing about your predictament today is you can be sure  in the furture it is going to be much much worse. Much worse.I love your blog. If I get chest pain in Boston one of these days I will go to your office with a ten point ROS clutched in my right hand and my left hand clutched over my heart.

 PS:  I know you work in Boston  because  you said  your collegue who sent you the 3 page note worked at the
BEST HOSPITAL IN THE UNIVERSE. Everyone knows that is code  for  BOSTON.

Ha!

Very entertaining and intuitive thoughts, indeed.  I am an exercise physiologist working and cardiac and pulmonary rehab and we are going through a massive chart audit process called an "ADR" (Additional Documentation Request) from Medicare right now so I feel your pain!

Where is the common sense?

Also, do you think tort reform is ever going to be addressed in health care?

Thanks!

THE ROS IS CLINICALLY A NET NEGATIVE!  Finally, someone saying something about this.  The ROS only leads to taking away time to discuss, review, reinforce, and remind patients about the real issues facing the patient.  Imagine complex surgical or procedural risk/benefit discussions being pushed aside for this garbage!  Patients are verbose enough and are sometimes difficult to keep on track to begin with. 

What does it mean if the ROS is 50% "positive"?  Nothing, of course!  Only that the patient probably has an anxiety disorder,  since there is no way a human being can literally have acute abnormalities in half the body symptoms at one time. And, we're even expected to review each "positive" individually?  Crazy. 

 I have spent hours and hours reviewing the "criteria" for correct coding.  It is so complex it takes an IQ of 150 and a PhD just to remember the criteria.  MDM Point System, moderately-complex this, 2-9 bullet points that, x body systems, y stable vs. acute problems, z data review points, etc, etc.  Impossible. 

How the idiots who agreed to such a framework with CMS is beyond me.  Oh, I forgot, they're not really practicing, otherwise they wouldn't be in a position to do so!  And now we're going to be accused of "fraud" if we can't abide by these obtuse rules? 

We need to junk the whole system and go by time spent, just like lawyers.  Charge whatever you like per minute/hour, but it has to be displayed/posted up front. 

 P.S.  I thought it only takes 2-9 (emphasis on the 2) ROS systems reviewed to get an EXTENDED ROS, to get DETAILED history, when combined with MODERATE MDM, gets you 2/3 criteria to get you qualified for a 99214?  Of course, it might depend on 1997guidelines vs. 1995, and after that, which Medicare carrier you actually have at the moment.  Fun, huh?

Dr Michael,

Llast year  i studied the documentation  literature extensively  and worked out a stamp that could be placed along side the progress note and with about 5  checks you could figure out the correct billing level of care. I tried to use it and was told this was forbidden as it suggeted somehow we

were gaming the system. The implication being that we should  code intuitively  rather than

logically and systematically.  Without such a guide coding is impossible and,moreover, indefensible when asked to defend it  in the  future .