©2012 TrustHCS Confidential
©2012 TrustHCS Confidential
Getting it Right: How to Improve Physician Documentation in Practice
Deborah Robb, BSHA, CPC Director, Physician ServicesTrustHCS
Lori Owens, RHIT, CCS Director, Operations Physician ServicesTrustHCS
©2012 TrustHCS Confidential ©2012 TrustHCS Confidential
Understanding Documentation: • Bad habits• Misconceptions• Technology Gaps
Designing a Training Manual for Providers:• Make it specific for your organization
Lessons Learned:• Documentation auditing• Coder trending• Revenue patterns
Objectives:
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Bad Habits“Click Happy” –clicking on boxes even when they are not necessary for the visit
“The Copier” - changing of a sentence or two but otherwise the note is identical to the previous visit
“The Hearsay” – I did that I just didn’t document it
“The Paste” – this is using another providers note and just adding to it
“The Anonymous” – not signing off
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Misconceptions
“The computer levels my visit.”
“Just tell me what to add.”
“Just pick a diagnosis that’s
similar.”
“The visit is the same so I can
use last month’s note.”
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• Diagnosis dropdown boxes are limited on diagnosis choice
• Free text is not recognized with most EHRs and the content is not counted towards the level of service
• Check boxes are convenient but don’t provide enough detail related to specificity or location
• Many EHR systems are not specific to specialty providers
Technology Gaps
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Developing a Training Program
Getting Started
• Provider documentation• Strong Points• Missing Components
• Coder skill sets• Educational Needs
• EHR functions• Checkbox clicking• Copy and paste
• Guidelines used• 1995 Guidelines• 1997 Guidelines
• Diagnosis specificity
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Documentation Guidelines Office or Other Outpatient Visits Inpatient Hospital Visits Initial Hospital Care Services Subsequent Hospital Visits and
Hospital Discharge Management Services
Consultations Critical Care Incident of Services Observation Care Prolonged Services Split/Shared E/M Service Local Coverage Determination National Coverage Determination Examples of E/M Service
Sample Physician Training Manual
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Begin with a chart audit• What is missing in E/M components• Are diagnoses described to the highest specificity• Can you provide accurate ICD-10-CM diagnoses with the
information documented Determine what is missing GAP analysis
Determine training needs• Utilize audit findings to target training by provider or group
Physician Documentation
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ICD-10 Documentation Analysis
Deficiency Type # Reviewed # Deficiencies % Charts with Deficiency
Overall 96 21 21.88%Acuity 24 0 0.00%
Disease Type 24 5 20.83%Disease Stage 3 1 33.33%
Laterality 8 6 75.00%Site Specificity 10 5 50.00%
Combination Codes 2 1 50.00%E-Codes 0 0 0.00%
7th Character (Fractures) 1 1 100.00%7th Character Episode of Care 1 1 100.00%
Terminology 23 1 4.35%Under-dosing 0 0 0.00%
Time and Tables 0 0 0.00%Obstetrics 0 0 0.00%
Summary Dashboard
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• Be specific
• Identify strong points
• Review what is missing
• Identify lost revenue
Training Providers“Follow the
specs.”
“The entry is phenomenal.”
“Where are the plans for the guest bath?”
“The price of hardwood is going up. We need
to decide now.”
©2012 TrustHCS Confidential ©2012 TrustHCS Confidential
99213
99214
99215
Revenue Differences
RVU GPCI TOTALWork RVU 0.97 1.000 $33.00 Non-Facility Practice Expense RVU 1.10 0.851 $31.85
Malpractice RVU 0.07 1.023 $2.44 Non-Facility Total RVU 2.14 $67.29
RVU GPCI TOTALWork RVU 1.50 1.000 $51.03 Non-Facility Practice Expense RVU 1.54 0.851 $44.59
Malpractice RVU 0.10 1.023 $3.48 Non-Facility Total RVU 3.14 $99.10
RVU GPCI TOTALWork RVU 2.11 1.000 $71.79 Non-Facility Practice Expense RVU 1.95 0.851 $56.46
Malpractice RVU 0.14 1.023 $4.87 Non-Facility Total RVU 4.20 $133.12
©2012 TrustHCS Confidential ©2012 TrustHCS Confidential
• Determine who is best suited to provide findings and training to providers
• Provide reference materials for what is being presented• Cite AHIMA, CMS, CPT Asst., Coding Clinics
• Provide a quick reference guide for documentation needs
Coder Skill Sets
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Are providers using canned text for click boxes?• Can you validate the work effort for the visit?• Are the descriptions explicit enough to code now and planning for
ICD -10?• Are IT modifications needed?
What is your policy for copy/paste of information?• Can you demonstrate what was done today?• Are changes in the documentation clear and concise?• Is the information pertinent for what is needed now and planning
for ICD -10?
EHR Functions
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• Are you using 95 or 97 E/M guidelines?• Body Areas – 95• Organ Systems – 97
• What did the audit results demonstrate?
• Are you going to require a change in what is used?
Guideline Usage
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• Do the providers understand what is needed?
• Do the coders understand the requirements?
• Have you done a GAP analysis?• Recommend doing this by specialty and identify the top 20
diagnoses
• What ICD -10 training has been done?
Diagnosis Specificity
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When should we start?
• Orientation
• Active staff
Training Program Implementation
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• Education related to documentation should be done within the first few weeks of on boarding
• All providers need training related to• E/M guidelines utilized• Incident To if applicable• Split/ Shared if applicable
• Begin the ICD-10 discussions of what will be needed• Start with documentation terminology changes• Highlight the specialty specific points in your first session
On-Boarding Program
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• Start with known documentation challenges
• Explain how reimbursement will be affected by lack of documentation
• Provide timelines for implementation of changes needed
• Provide training specialty or clinic specific• Provide examples of top 5 diagnoses that the documentation is
good and can convert to ICD -10• Provide the top 10 diagnoses and how documentation is lacking
Active Staff
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Starting a Training Program
Who should be involved?
Location Specific Rural Areas
General Session Breakout Sessions
Specialty Specific Large Groups of Specialties
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• Pick 3 encounters and code them with the providers
This is a perfect time to have the provider audit their own encounter to check all components of E/M leveling at this time
Provide the codes that would be used and review what is missing and why
Ask for the providers input on what would help them achieve the correct documentation
Specialty Specific
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• Most common for family practice
• Provide education related to the types of patients seen frequently
• Start off with the top 20 diagnoses
Location Specific
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• Specific training by specialty
• Identify gaps:• Specificity?• Laterality?• Acuity?• Location?
Progression to ICD-10-CM
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Evaluate training success!
Auditing scores
Complete documentation
Clean claims
Conclusion