Combatting Note Bloat: A Coder’s Perspective
By Heather Sprinkle, CCS
When you hear the phrase note bloat what do you think? I start envisioning a note that resembles a blown-up balloon ready to burst. Now that's a funny thought! But that's not really what it is. Note bloat happens when a medical document is overflowing with information that is not necessary for the treatment of the patient on a given date of service. One might think that having a lot of information in one document would be beneficial to the coder. While this might be true in some circumstances, it generally is not. In fact, note bloat can actually have a negative impact on the revenue cycle.
Note bloat is becoming more and more common with the use of EHRs and computers. When I first started coding, physicians would either handwrite a note or dictate a note for a transcriptionist to type. You wouldn’t see the physician spending the time writing down all the patient’s labs from the past five years or even listing out history that doesn’t pertain to the current issue. Nowadays, with the technology in EHRs, almost every note contains nonessential details. With just a click or two of the mouse in an EHR, all of the patient’s history is loaded into that note.
The problem with note bloat is the physician can pull all that unneeded information into a patient note and potentially bill out a higher E&M level than the documentation and nature of presenting illness warrant. Some physicians bill for themselves so these claims go out the door until a potential audit or denial takes place. These facilities can lose out on money by spending time looking into denials and/or having to pay back money from upcoding. If a coder bills out the physician’s claims, it can potentially impact the revenue cycle by taking the coder twice as long to code the account by deciphering what information is pertinent to the patient visit.
Here are some examples of note bloat:
A 5-year-old healthy child comes in for an earache. The birth history and completed family history (that do not pertain to an earache) are still documented in the note.
A patient comes in for a follow-up on their INR testing. Instead of discussing their diagnosis, current level, or what the trend is, the physician drops in all of the patient’s past INR levels. This is not necessary as they are already listed in the patient’s chart and could just be summarized in the current office visit.
A patient comes in for a workman’s compensation injury visit. The physician adds information to the visit that does not pertain to the injury such as unrelated chronic conditions and other lab or radiology tests.
To help deflate note bloat, we recommend first educating providers on the impact of their documentation. This can not only help improve revenue cycle integrity and coder efficiency, but it can also support more efficient continuity of patient care.
If you’re struggling with any of the common issues addressed in this article, we can help. Elevate Medical Solutions offers several services to help your facility combat note bloat. Contact us for a complimentary consultation.
