5. Q&A: Ensuring proper behavioral health encounter documentation

Q: What are some documentation gaps in behavioral health encounters?

A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete documentation of social determinants of health (SDOH) and family history. This is a space where we are seeing more queries, so we need to ensure the documentation is complete, consistent, and not conflicting. That helps us to make an accurate code assignment, not only with the primary diagnosis, but with the secondary diagnosis that can also impact the risk of mortality or the severity of the illness.

Documentation gaps in any space hinder precise coding. It leads to inaccurate and incomplete reporting, and it just does not paint a clear picture of what is happening with that patient. We need clear communication between providers and coders because we need to make physicians aware of the way CMS classifies different diagnoses and the details that are needed for us to be able to code to the high specificity, if it's applicable. This helps to ensure that the entire medical record supports the selected ICD-10-CM codes.

Common documentation gaps in behavioral health include lack of specificity in the following:

• Condition severity: Not documenting the severity of a condition (e.g., mild, moderate, severe) can prevent the selection of the most appropriate and granular ICD-10-CM code.
• Symptom details: Insufficient detail about symptoms, their duration, and how they impact the patient's functioning can lead to broad, less specific codes instead of precise ones.
• Treatment details: Failure to document specific details of behavioral health treatments, such as the duration of therapy sessions or the type of psychotherapy, can make it challenging to align codes with services rendered.

Also, in this space, we often see incomplete SDOH information, such as:

• Underutilization of Z codes: Documentation often fails to include information related to social factors that significantly impact health outcomes, which can be captured using ICD-10-CM (categories Z55-Z65). For example, if the family history, personal history, surgical history, or SDOHs meet secondary diagnosis reporting requirements and help to paint a picture of the severity of the patient, we want to make sure that we're picking those up as well.
• Lack of data for vulnerable groups: The absence of detailed SDOH information prevents the proper coding and monitoring of health disparities affecting vulnerable groups. If we don't capture it, the facility cannot trend the risks that are involved with its patient population and is not able to match them up with organizations that can help with the challenges that patients are experiencing. For example, for homelessness, finding them a group home or other housing; or for food insecurity, matching them up with an organization that helps with delivering food.

There can also be a lack of documentation of family history, including mental and behavioral disorders, which are coded with Z codes but are often overlooked. So, for example, if patients have a family history of mental illness, if they meet secondary reporting requirements, we will want to make sure we capture that.

Insufficient provider/coder coordination can also result in documentation gaps, such as:

• Misalignment: A lack of alignment between clinical documentation and the specific requirements for coding can lead to missed opportunities for using more precise codes. Ultimately, this is why many times we have to place a query to try to obtain more information regarding the particular diagnosis.
• Inadequate training: Insufficient coder education and poor alignment with coding practices can contribute to these deficiencies. One of the things that I think is very helpful for coders is seeing where denials are coming in in this space. It helps us to learn where we might need opportunities to enhance our documentation and work with our physicians.

These gaps in documentation are problematic because they can lead to:

• Inaccurate coding: Vague documentation leads to broad codes, which don't accurately reflect the patient's condition, contributing to incorrect data.
• Negatively impacting data and outcomes: The lack of detailed documentation can affect data collection, leading to a misunderstanding of disease prevalence and patient outcomes.
• Improper billing and reimbursement: Incomplete documentation can result in improper billing and reimbursement, affecting the financial stability of the hospital, the practice, and the physician.

Editor’s note: This article originally appeared in JustCoding. This information was provided by Leigh Poland RHIA, CCS, CDIP, CIC, during HCPro’s webinar, “Mind the Gap: Strengthening Behavioral Health Coding and Documentation.”