Insights: Article

Seven Key Strategies for Opioid Documentation

By Susan Rohde

March 13, 2019

Once considered a “teenage” or “young adult” problem, opioid usage and dependence has slowly crept into the elderly population as increasing chronic pain conditions continue to rise. The Department of Health and Human Services declared an opioid crisis in late 2017, stating that at least 91 Americans die each day of an opioid overdose and the numbers are increasing. The Centers for Medicare and Medicaid (CMS) took notice, and in August 2018 released a Medicare Learning Network (MLN) discussing the importance of not only documenting current patients’ opioid usage, but also the likelihood of all other patients starting on opioids.

Opioid Use Reporting
Medicare has declared that opioid discussion is an integral part of the Initial Preventive Physical Examination (IPPE/Welcome to Medicare Exam/G0402) as well as the Annual Wellness Visit (AWV/G0438/G0439) and if not documented correctly, there is a threat of denial. In the past, the Medicare Cost Report has viewed the IPPE and the AWV as an opportunity for discussions on a variety of topics such as depression, cognitive impairment and functional ability. As of August 28, 2018, according to the MLN Matters SE18004, CMS states that “a review of opioid use should be a standard part of the reporting elements”.

Under the “Review of Medical and Family History” element, CMS states “Medicare would like to emphasize that the review of opioid use is a routing component of this element, including OUD (opioid use disorders). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.” Prior to this directive, CMS simply stated “medication review” was a requirement.

While certain specialties, such as orthopedics or pain management, have a higher population of opioid usage, family practice/internal med providers are commonly providing the IPPE/AWV services. Failure to document opioid review can result in claims denial as this is currently under investigation by CMS. Documentation should show that the provider assessed the benefit of non-opioid therapies as an alternative treatment method.

Seven Key Strategies
What does this mean for your practice? Documentation is key. The American Health Information Management Association has developed seven key strategies for proper clinical documentation that should be present in every entry in a patient's health record, regardless of diagnosis. Documentation that does not meet each aspect of these characteristics can lead to inadequate patient care.

The seven strategies are:

  • Legibility. Although we are living in the digital age, not every facility or provider has migrated to an electronic health record. When provider documentation is illegible, it affects not only the accurate coding of an encounter but also patient care. If a patient is being treated for a condition and any piece of diagnostic documentation is illegible, treatment could be jeopardized.
  • Reliability. A 65-year-old male patient has a follow-up visit for COPD. The provider documentation mentions that the patient is being treated for the COPD and he should continue his methadone therapy. However, there is not a diagnosis anywhere in the record that correlates with the methadone therapy. As a result, the patient's record would be considered unreliable. By adding a diagnosis of OxyContin addiction, the reliability characteristic would be met.
  • Precision. According to Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CP, author of“Clinical Documentation Improvement: Principles and Practice,” a precise record is one that is accurate, exact, and strictly defined. The more details a provider can document about the patient's condition, treatment, and patient-provider interaction, the more precise the record will be. A diagnosis of drug abuse without documenting the type of drug that is being abused is a perfect example of imprecise documentation.
  • Completion. Complete documentation is imperative to ensure the patient's continuity of care. Providers must not only offer topnotch documentation to guarantee the completeness of the medical record, they also must authenticate every entry with their signature and date. When a provider documents that the patient had abnormal laboratory findings related to a drug screening but fails to document what those findings were, the record is considered incomplete.
  • Consistency. For a record to be considered consistent, there should be no conflicting documentation. For example, suppose the attending provider documents "39-year-old male patient was admitted for opioid use. This is the second admission for opioid abuse in the last two weeks for her." Is it opioid use or abuse? Is the patient male or female? Even little details matter for consistency.
  • Clarity. Clear documentation means leaving no room for interpretation and being as informative as possible. For example, a provider knows his patient, admitted with fatigue and lethargy, is addicted to heroin but fails to document the addiction. This leads to ambiguous documentation and can possibly be detrimental to the patient's continued care.
  • Timeliness. Providers' schedules are demanding—many see dozens of patients every day. These demands create a time crunch, with documentation often becoming a lower priority. However, if a diagnosis or a treatment is not documented, the patient is put at risk. EHRs relieve some of the documentation burden, with providers frequently carrying an electronic device while rounding or seeing patients. Nevertheless, timely documentation remains a problematic issue.

Organizations need to ensure that the proper information is being captured on a consistent basis. This is an issue of both quality of care and financial reimbursement. With the transition to new opioid guidelines, organizations are encouraged to routinely perform internal and external reviews to identify opportunities for documentation improvements and needs for additional education for providers and health information staff.

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