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10 Articles in Volume 8, Issue #8
Botulinum Toxin Type-A in Pain Management
Chronic Migraine: An Interactive Case History
Consistent Documentation Drives Compliance
Muscle Physiology, Kinetics, Assessment, and Rehabilitation
Non-surgical Decompression Treatment for Carpal Tunnel Syndrome
The Pseudo-RSD Pain Patient
Therapeutic Laser Evolution: Part 1
TMJ Pain and Temporal Tendonitis with Autonomic Features
Topical Use of Morphine
Toward a Neuroethics of Pain Medicine

Consistent Documentation Drives Compliance

I have been to a number of different conferences this year and see a growing trend of pain specialty clinics adding orthopedic, physical therapy, massage therapy, chiropractic, etc. Some of you are already working in such a clinic. While this provides the patient the benefit of going to one clinic, there may difficulties in communicating the necessary patient documentation and care between providers and support staff.

Most doctors still dictate and handwrite in charts. Too often the dictation is not back in time for the next encounter or, even worse, an encounter where your other provider sees that patient. This disjointed type of record keeping can get your clinic in hot water! An audit could be stifling to your clinic’s existence.

In this article, Dr. Ted Arkfeld—a past contributor to this column and a tech-savvy user of EMRs over the years—points out the importance of having consistent documentation in proving compliant patient care. He also discusses Evaluation and Management (E/M) guidance for your exams and followups.

The rapid expansion of pain management clinics and the fact that many are turning into multidisciplinary clinics throughout the country has provided patients with a one-stop shop for healthcare. The advantages can be numerous for physicians and non-physician providers in delivering various services in different specialty areas. The problems and/or red-flags can also be numerous due to insurance carriers viewing these arrangements with suspicion because of a few unscrupulous doctors engaging in abusive billing, coding, and documentation procedures and, at the worst, committing fraud. Utilization review companies look at the consistency of the documentation of everyone involved in the patient’s case file. If the file lacks consistency, then the stage is set for further investigation and a possibly negative post-payment audit requiring large sums of monies to be repaid.

Pain Scales

There has been considerable progress in pain assessment, theory, and measurement in recent years. One method employed every day in offices nationwide is the use of a numeric rating scale where pain patients are asked to give a rating on a 0 to 10 scale. This type of scale is easily understood by patients and is obtained by either written or oral means. The main problem is that both patient and doctor may walk into the exam room with a different pain scale definition.

For example, a provider asks a male patient on a scale of 0 to 10, what is the pain rating today? The patient responds while sitting very comfortably with no visual signs of distress that he is currently at a 10. The doctor is now put into a very delicate situation of having to determine what is this patient’s motivation for such a high pain rating when he appears to be doing just fine. The patient may not realize this level is in conflict with the physician’s own definition. The patient simply based their definition on what was explained to them during a previous visit.

The patient may also find himself in the middle of two or more providers he may be seeing in the same facility who cannot agree on a pain scale definition among themselves. A patient first sees Dr. A, who inquires about their pain level and, if the rating is deemed extraordinarily high, is instructed on that doctor’s own definition. The patient then goes to see provider B, who is of another specialty, and is asked what his pain level is for the day and, when given the scale number, tells the patient that can’t be right and then gives their definition. The poor patient is caught in the middle and leaves both irritated and concerned that these providers cannot agree on a pain scale definition.

Sometimes, the patient who is very informed but also highly motivated to play the system, will tell each provider what they want to hear. When the patient sees provider A, who is a physical therapist, chiropractor, nurse, etc., he gives a low pain rating. Shortly following that visit, the patient sees Dr. B, who is a pain management physician and the one writing the scripts. The patient tells Dr. B that his pain scale rating is much higher than what he had indicated to provider A in order to get pain medication. The patient has manipulated the flaws in the definition and documentation of the office to obtain what they want. More importantly, this situation creates a big red flag for insurance carriers regarding medical necessity.

Functional Pain Descriptions

The medical necessity for most third party payers and Medicare states that a patient’s pain level must be decreasing and their functional capabilities increasing. The easiest way to accomplish consistency for both patient and physician is to adopt the following functional pain descriptions.

0 = No Pain
1-2 = Annoying pain that is forgotten during activity
3-4 = Pain that interferes with some activities
5-6 = Pain that prevents some activities
7-8 = Pain that prevents most activities
9 = Pain that causes outcries and makes one bed-ridden
10 = Pain so severe that one might even consider such drastic measures as suicide.

This type of scale also allows a better method for patients in comparing pain levels from one day to the next. While it is hard to distinguish between levels of pain, inquiring about pain effect on the patient’s activities makes the evaluation much simpler for everyone. In addition, by inquiring about the patient’s activities, you shift the focus away from their pain and move it to increasing their functional activities of daily living, which is crucial in treating chronic pain patients. Documenting functional activities can be done by having the patient fill out questionnaires such as Oswestries, Roland Morris, Neck Disability, etc.

Documenting Objective Findings

Unfortunately, many physicians of all specialties that treat musculoskeletal conditions do not adequately document the objective findings from the orthopedic and neurological evaluations. This results in a failure to differentiate tissue involvement or isolate the pain generator. This problem is twofold, with the first being the documentation system the physician utilizes, and second the use of a cookie cutter approach to the examination.

In today’s healthcare environment, checkbox examination forms are outdated and should be abandoned. Handwritten notes pose problems due to both legibility and detail quantity. Many electronic medical record systems are too rigid and do not allow for both customization and randomization of the textual output for your report. Too many EMRs do not print out a “story” of the patient and instead print out one-liners. Insurance companies are frowning on such apparently incomplete documentation.

In multispecialty offices, the electronic medical record system must be flexible enough so that all physicians of differing backgrounds or specialties can implement macros or templates without interfering with another provider’s documentation in the same office. In the chronic pain clinic where I previously practiced, there were MDs with various subspecialties as well as DCs, PAs, and PTs. Our anesthiologist, being very computer savvy, spent an entire weekend making macros and templates for the new EMR system, only to have all of his hard work accidentally deleted by another provider on the following Monday. A good EMR system must allow for customization of various independent workflows that allows the other providers to view associated screens but cannot get overwritten. Workflow management in a good EMR will achieve consistency for all providers managing or treating the same patient. Textual randomization allows creation of documentation unique to the patient while still achieving a consistent approach to patient care management.

Another outmoded aspect is the cookie cutter approach to the examination process, where one size fits all no matter what the presenting complaints of the patient. Locking in on one or two evaluation and management codes for new and established patients must be discarded and replaced with a more flexible approach based on the history guiding the examination.

Evaluation and Management (E/M) Code Selection

Consistency is an absolute must in the E/M code selection for new and established patient visits. If the criteria varies from one provider to another in a multi-specialty clinic, the group, as a whole, takes on the risk of a disgruntled patient being overcharged on co-payment, or becoming a blip on the radar screen of a probing insurance company. Implementing a compliance program, which educates physicians and non-physicians on the correct E/M selection, is necessary in order to correctly bill and code for such services.

Another vital element is an EMR system that guides the physician during the history, examination, and medical decision-making process. I call this front-end guidance as opposed to back-end assessments found in many EMR systems. The front-end guides the provider by informing them of what the criteria is for the different levels of E/M codes, whereas the back-end assessments waits until the provider has finished inputting all the information and then indicates if they have met or exceeded the requirements for the various E/M levels. If the requirements are not met for a specific level, then the provider must go back and fill in the missing items. This can be a time-consuming process since each time new information is added, the provider has to get his/her work graded by the system. The danger is that if providers just start adding items in order to meet or exceed criteria, most likely it would not stand up to a post-payment audit.


Multi-specialty offices can provide a wonderful spectrum of services for patients and offer rewarding challenges for providers. However, due to the very structure of these facilities, they also are closely scrutinized by Medicare and other insurance carriers. In order to operate in a compliant nature, consistency between providers in the definition of a pain scale, E/M code selection, and documentation must be achieved.

Last updated on: January 28, 2012
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