DRG Coding Advisor: Motivation and time limit physicians’ coding education
Medical decision-making is most important element
In most successful physician practices, the doctor’s time is usually fully scheduled, leaving little time for documentation that would meet coding guidelines.
That’s why it’s a good idea for physicians to seek the advice and expertise of HIM professionals and coders to learn what it is that payers want them to document.
"You need someone who has knowledge about outpatient coding," says C.B. Daniel, MD, medical director at Methodist Extended Care Hospital in Memphis, TN.
The typical problem physicians have is they have an established way of approaching a patient visit and of documenting that visit, and it works well for them, Daniel says. "But does it work in a way that the payer signs off on it and says it’s sufficient documentation?"
Daniel says the way to make sure your coding meets payer standards is for a physician to solicit an outside independent audit of the charts and documentation. This will show what the strong points and weaknesses are.
This auditor should be someone knowledgeable about outpatient coding, he adds.
"I’ve been exposed to outpatient and inpatient coders, and they don’t like to cross into each other’s turf, so you generally don’t find anybody who does both jobs at the same time," Daniel says. "It takes a person with a background in outpatient coding guidelines."
Also, physicians will need to know the 1997 documentation guidelines endorsed by Medicare as well as the 2000 guidelines, which soon will be the standard to which they are held.
Other reports to read include the Medicare carrier bulletins and the evaluation and management section of the current CPT book.
Every year, Daniel recommends that physicians read the American Medical Association’s (AMA’s) coding book’s coding principles, which typically has subtle changes from year to year.
The key points that physicians sometimes incorrectly document with regard to coding standards include the following:
- Medical decision-making, which is the most important element for the physician to document, helps to set the proper evaluation and management coding.
- Patient history determines the extent of the exam and justifies the diagnostic work-up.
- Physical exam usually is the least documented of the key elements.
Other elements that should be included in documentation include counseling, coordination of care, nature of the presenting problem, and time of the visit.
Keeping these key points in mind, these are the misconceptions and problems many physicians have with their documentation, Daniel notes:
1. Deciding who takes the patient history.
Physicians sometimes incorrectly assume that they must take each patient’s history themselves, but this is not true, Daniel says.
"The guidelines allow you to do a past history and a social history and have it collected by someone else, with the doctor signing off on it," Daniel explains. "Some offices have computerized forms that the patient can fill out at a computer terminal, or an office person can bring the patient back and interview the patient to see why the patient is there and what the history is."
2. Determining how much information is needed on new patients.
There’s quite a bit more documentation required when you’re seeing a new patient. On each new patient, a doctor must document the patient’s history, the physical exam, and the medical decision-making element.
"To establish payment on existing patients, you need only two of the three key elements to meet guideline criteria, so you call fall off in one area," Daniel says. "But with a new patient, all three areas have to met the level of an evaluation and management visit that you’re billing for."
Suppose a new patient comes in and the physician takes an extensive history and an extensive exam. Both are documented and straightforward, but the diagnosis is skin rash or poison ivy. The payer won’t pay for the extra work the physician put into the history and physical exam.
"There’s a higher standard for documentation for new patients, and the physicians need to understand that," Daniel says.
Instead, what the physician should do is take the new patient’s history first and then use that to determine how much of a physical exam is necessary. The more complaints the patient has, then the more extensive the physical exam needs to be, Daniel says.
For instance, a patient who complains of chest pains may have a serious problem that would require a detailed physical exam.
"From a clinical standpoint, you approach a patient one way, but from the documentation standpoint you do it almost the opposite way, which is: What was the diagnosis, and what did we do, and how did we get there?’" Daniel explains. "It creates a lot of confusion."
3. Medical decision-making is the art of medicine.
"It’s the physician’s knowledge of the patient’s history and previous medications," Daniel says. "And it’s difficult to document the mental steps you went through to make that decision, to meet the criteria."
But under coding documentation guidelines, a physician simply can’t say a patient has congestive heart failure or some other diagnosis. The physician has to prove how he or she got to that diagnosis. "It’s time-consuming and offensive to physicians," he says.
However, according to Daniel, with computer software and best-practice guidelines, the medical decision-making process can be simplified.
"I have a hand-held computer that I work with now," Daniel says. "If you’re an orthopedic surgeon or specialist who sees the same problems over and over, it’s easy to buy something that’s automated."
For general practitioners, this may be less convenient, so they will have to take the extra time of documenting their medical decision-making process with each diagnosis.
4. Documentation often is lacking basic elements.
Physicians sometimes fail to document their review of systems, which is the history in which a patient is queried about different organ systems to determine whether the patient has any complaints or problems. These include such conditions as blurry vision, double vision, and difficulty in hearing.
Most of the time, the physician will get to know the patient and make informal queries during the consultation, such as, "You don’t look good. Have you lost weight, or are you hurting?" Daniel says.
Dictate informal consultation into chart
"Most of the time, that sort of informal consultation doesn’t get dictated in a formal manner into the chart, and it needs to be," Daniel adds.
Likewise, the coordination of care needs to be documented. "In a primary care physician’s office, that means you’re the guy who’s responsible for everybody else’s action or inaction," Daniel says.
When a patient is referred to a specialist, who then sends a report back to the primary care physician, it will be necessary for the primary care physician to spend time to discuss the report with the patient. The same is true when the primary care physician is the one who gives the patient test results from another site.
"Primary care physicians do this day in and day out, and we don’t even consider that this is something we could be reimbursed for," Daniel says. "But we can be reimbursed, and this could contribute to a higher level of visit."
Physicians sometimes also fail to properly document the nature of the presenting problem. This documentation should answer the questions: Why is the patient here today? What is the problem?
"Say it is a routine case of diabetes or hypertension. Then the physician could document that the patient is there for further evaluation and management of diabetes or hypertension," Daniel says.
Stated that way, the payer won’t argue with the need for a physician to see such a patient on a routine basis.
5. Document time spent with the patient.
Whenever a physician spends a lot of time counseling a patient or explaining a patient’s problem, then there’s a cost in time that should be documented.
"Document the time you spend, because it will support your reason for documenting the visit at that level," Daniel advises. "Say the patient has chest pain and needs a cardiac catheterization, and the patient brings in his children who want to know why their dad needs that heart catheterization."
Explaining the procedure and the need for it to the children takes time that should be documented. "You could simply say, The patient was seen at a visit today, and the family was counseled about the need to proceed with a heart catheterization, and the total time was 30 minutes,’" Daniel explains.
"If you do a level of visit in less time than is allocated, you’re not punished," Daniel adds.
Likewise, physicians should always document when they go over the allocated time, Daniel says.
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