Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.
For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex. In order to prevent this document:
Your differential diagnosis and ideally why you were concerned about them
Instead of just checking a box stating that you reviewed old records take 5 seconds to summarize their last visit. (i.e.: Admitted in May for CHF exacarebation, EF 50% by Echo, discharge on lasix). This helps the coders prove that you looked at the chart and gives you 2 points for medical decision making.
Document the response or initial lack of response to therapy. (i.e.: Asthmatics might get discharged home and still qualify for critical care time or a level 5 chart if you document how they initially responded to nebulizers and it was the magnesium that finally broke the cycle.)
I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.
More to come...
References
Adapted from Michael A. Granovsky's ACEP lecture entitled :"RVU Killers: The Most Common Reimburshment Documentation Errors"
