Thorough documentation is critical not only to proper reimbursement but also to good patient care. Unfortunately, it is often time-consuming and cumbersome. One simple solution our practice has implemented is a visit-specific encounter form.

How it works

Recently, our practice’s main insurance carrier began to require extensive documentation for routine gynecological exams, including notes regarding pertinent negatives, to support billing codes for this service. In addition to needing to meet our carrier’s new requirements, we also wanted to assist our physicians in collecting information about the patient’s history and health concerns. Previously, collecting this information was the responsibility of the physicians or nursing staff and, if done completely, required up to half the appointment time allotted for a gynecological exam. As a result, our physicians had little time left for preventive counseling or patient education.

The encounter form we developed (

) has met both of these needs. It has shifted the responsibility for collecting patients’ health information to the patient, which gives our physicians more time during the encounter and engages the patient in his or her care, and it includes the pertinent negative findings required by our carrier, which improves our billing and reimbursement.

When the patient checks in at the front desk, the secretary hands the patient the form and asks her to complete it while she is waiting to be seen. The physician then performs the exam and documents the findings on the form. Checking the “normal” box indicates that a pertinent negative has been reviewed. Checking the “abnormal” box and circling the pertinent findings documents the physical findings. The form requires minimal handwriting by the physician and enables all documentation to be complete by the end of the visit.

Patients generally do not object to filling out the form, but we do get an occasional complaint. Our secretaries and physicians respond by encouraging patient participation in the process and stressing the importance of the information gathered. This message is reinforced when the physician actually uses the form during the visit to review the patient’s information. If a patient does not complete the form, we do not make an issue of it. Our nursing staff helps those patients with sight or reading difficulties to complete the form.

Many of our physicians initially complained that there was not enough room on the form to document significant problems or additional medical issues. This was done intentionally. If documentation of the additional problem or finding takes up significant room, it is likely that the problem requires a significant, separately identifiable service that can be coded using the appropriate evaluation and management (E/M) office visit code and a supporting diagnosis code. By not building in room for this on the gynecological encounter form, we are encouraging our physicians to dictate a separate encounter note for the separate problem. This keeps the documentation very specific, and it is easy for reviewers to identify which parts of the exam correspond with the routine pelvic exam and which correspond with the E/M service.

Although not required for most carriers, exam documentation for all organ systems is included on our form; however, this is kept general in nature. Should the patient require a more comprehensive preventive history and physical, we use a commercially available history and physical form to document these areas.

Results

The gynecological encounter form has been well received by the physicians in our practice. Because the form covers most of the routine questions, the physicians can devote more time to patient education and counseling. Because the form prompts them to document all pertinent negative findings, our physicians are seeing reimbursement benefits as well. While a 30-minute visit never used to seem like enough time to do all that was required, our physicians now have time to be thorough in their care and in their documentation.