©2012 trusthcs confidential getting it right: how to improve physician documentation in practice...

©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:


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


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.”


• 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


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


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


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


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


• 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.”


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






• 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


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


• 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


• 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


When should we start?

• Orientation

• Active staff

Training Program Implementation


• 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


• 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


Starting a Training Program

Who should be involved?

Location Specific Rural Areas

General Session Breakout Sessions

Specialty Specific Large Groups of Specialties


• 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


• Most common for family practice

• Provide education related to the types of patients seen frequently

• Start off with the top 20 diagnoses

Location Specific


• Specific training by specialty

• Identify gaps:• Specificity?• Laterality?• Acuity?• Location?

Progression to ICD-10-CM


Evaluate training success!

Auditing scores

Complete documentation

Clean claims

Conclusion

©2012 trusthcs confidential getting it right: how to improve physician documentation in practice...

Documents

trusthcs confidential

documentation analysis

training needs

training program

em components

previous visit

rvugpcitotal work rvu1

missing gap analysis