Physician Documentation and Coding: Are Doctors Prepared?

This abstract from the American Journal of Surgery entitled “Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering” hints at the fact that most physicians are not properly prepared for coding and documentation in the real world of medicine.

We all understand that patient care is the most important aspect of practicing medicine. In Med School, physicians are trained to take care of patients. Many even specialize in a certain area of medicine and take care of certain kinds of sick people.But what about documentation and coding? Why aren’t physicians trained on how to best document what they did on patients? Isn’t good documentation important to continuity of patient care? Isn’t this how they are to defend themselves in a (heaven forbid) medical malpractice case? Isn’t this how they get paid? If physicians don’t know how to document, they’re losing….and its more than just dollars and cents. They’re honestly robbing themselves of being a “Best Pracitces” physician within the healthcare industry. So….WHY is this not taught to physicians in their formal education?

“The purpose of this study was to survey surgical residents and attending for their knowledge of documentation and coding and their opinions about its importance in their training and practice.”

The convenience sample: 60 surgical residents and 46 attendings from 5 surgical residency training programs

“Similar portions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS (documentation and coding for physician services). The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attending stated that they were somewhat knowledgeable.”

So 82-89% of residents and attending do not feel adequately trained in DCPS. So how will they learn? Think about it…CMS, Joint Commission and all the other players have so many rules and regulations that doctors must play by; but the docs are never taught the rules in the first place. It seems that docs have to (a) learn the hard way by making costly mistakes (b) take initiative towards independent training or (c) continue to be losers in the area of documentation and coding.

Lemak Sports Medicine Adopts ComplyMD Surgeon Notes

When world class athletes are sidelined, they find Dr. Lawrence Lemak for his orthopaedic expertise. When a world class doctor seeks to improve his documentation, he finds ComplyMD. The solution to healthcare’s archaic documentation process is ComplyMD Surgeon Notes. 

 

“I haven’t seen a noteworthy change in any type of documentation solution since the dinosaur system I saw in 1970″, said Lemak. “We’ve chosen to implement ComplyMD at Lemak Sports Medicine because it’s a type of documentation process we’ve never before seen – and we like it. ComplyMD will revolutionize the way we document our procedures.”

 

Lemak Sports Medicine, located at Brookwood Hospital, consists of three practicing physicians and three fellows. ComplyMD Surgeon Notes is a great fit for Lemak because of their high volume of orthopaedic cases. Scheduled for an early summer implementation, ComplyMD will shift the cumbersome, antiquated process of documentation from redundant dictation/transcription to a smart, physician-friendly tool. ComplyMD enables the vivid documentation of patient health and accompanying procedures, immediately generating complete and accurate data that is instantly available to both his office staff and the hospital/facility staff. The value of ComplyMD’s artificial intelligence intrigued Dr. Lemak. The system adapts to his team’s documentation behavior, allowing them to focus more on patient care and still generate a compliant and complete operative report.

 

“Dr. Lemak is known for excellence in healthcare. We’re delighted he selected ComplyMD Surgeon Notes to be a part of his successful practice,” said Curtis Palmer, CEO of ComplyMD. “His extensive experience will allow us to further develop ComplyMD’s radical process shift in healthcare documentation.”

* * * * *

ComplyMD allows physicians to vividly document the health of their patients and the procedures administered during their encounters, immeidately generating complete and accurate data for physicians. ComplyMD shifts the documentation process to enhance rich data creation, improve efficiency and maximize productivity in healthcare facilities.

Lemak Sports Medicine: World renowned orthopaedic surgeon, Dr. Lawrence J. Lemak, has played an integral role in sports medicine and arthroscopy research. He specializes in sports medicine, arthroscopy and reconstruction of the knee, shoulder, hip and elbow. As a leader in the field of arthroscopy, Dr. Lemak has published articles in numerous medical journals and has given presentations in the United States, England, Europe, Japan and South America. Many professional sports organizations call upon Dr. Lemak’s expertise as he serves as Medical Director for Major League Soccer, NFL Europe, Professional Golf Association and the Ladies Professional Golf Association. He is also Team Physician for many colleges and universities throughout Central Alabama and the Southeast. He is the National Medical Director for PhysioTherapy Associates, a leader in outpatient physical therapy with over 600 locations throughout the country. Dr. Lemak serves as the Associate Dean of Entrepreneurial Medicine at the University of South Florida, and is a Trustee of Alabama State University.

Operating Efficiently

This short article brings to light the lack of lack of intra-operative IT system implementations in the U.S., along with the hope for “an uptick in adoption of health information technology under the twin prods of a falter economy and IT funding courtesy of the economic stimulus package.” With intra-operative being the least penetrated of the four areas of the OR market, it could potentially hold the greatest amount of opportunity. And with the stimulus package funding, the area with the most opportunity could be the greatest beneficiary of the funding. Here’s a little proof on how much the OR impacts a hospital’s bottom line: “The reality is the OR is the cash-flow engine of the hospital” says Kermit Randa, senior vice president of sales and marketing for Surgical Information Systems. “A hospital generates on average 65% of their margins from the operating room. According to the Joint Commission, 55% of the infections happen in the OR and well over one-third of the supply costs happen in the OR. You show me a poorly performing OR and I’ll show you a poorly performing hospital.”

The Results Are In….One Office Coder Tells Her Story on the Benefits of ComplyMD

Physicians who currently use ComplyMD, have seen great results in their documentation. They are more aware of the benefits of capturing accurate, real-time documentation: benefits to the patient, benefits to themselves, benefits to the hospital/ASC, and benefits to their office staff. Here, I’d like to focus on some great feedback we received from one practice’s office coder.

And I quote…

-Chart accuracy has improved by 75%.

-Specifically, our physicians are now documenting their (1) lesion removals and (2) incision and drainage of abscesses more accurately, resulting in more accurate coding and reimbursement for our office.

-The free-text availability in ComplyMD has proven helpful in coding procedures and diagnoses. Our physicians are able to better communicate to us exactly what they did, along with the exact condition of the patient.

-Our billing department has become a more efficient, productive place with the utilization of ComplyMD.

-Our work load has decreased by about 40%.

-Increased ComplyMD usage has decreased the frequency of phone calls to the hospitals’ HIM departments by 80%.

-ComplyMD promotes a more efficient, more accurate method of documentation and coding among healthcare professionals.

Real people. Real results. Why not document with ComplyMD?

ComplyMD: Surgeon Notes for Documentation

ComplyMD offers Surgeon Notes for physician’s OR documentation. It’s a tough job to capture the physician’s attention while he/she’s in the OR. The focus is on the patient – where it should very well be. But, once physicians are done with procedures, where does their attention go? Oftentimes, they’ll pick up a dictaphone, or jot down notes on their index card, or even rotate into the very next OR to begin the next procedure. ComplyMD is different. It can almost appear as disruptive, but don’t let that scare you away from the concept. ComplyMD captures the physician’s attention and directs it towards accurate, real-time, rich documentation of exactly what went on in that very OR with that very patient. And after documenting with ComplyMD Surgeon Notes, the physician is done. That’s it.

TAT: Turn Around Time for Transcribed Reports

Turn Around Time. You ask any HIM professional and he/she will tell you that TAT (Turnaround Time) is very important to the operational efficiency of their facility. A snippet in this article says, “strict control of TAT impacts operational efficiency, enriches data capture and documentation, further empowers clinical decision making and enhances patient care.” That’s pretty strong. The article primarily addresses TAT concerning transcribed reports. Many, and I regret to say, most physicians rely on dictation and transcription for their documentation and data capture. Transcription is almost essential to many facilities. But with the advancement of technology these days, wouldn’t one think that this issue of TAT could potentially be resolved (or minimized) with some type of technological application or improvement. I’m not saying “displace transcriptionists” by any means. What I am saying, is that I believe we can make their job easier and more effective towards driving operational efficiency within healthcare facilities. There are a number of ways to do this: templates or “standard” reports, voice recognition software, scribes, etc.

With ComplyMD, we enhance a facility’s operational efficiency with our process application. Our physicians use their standard templates (for their most common procedures), have the option of dictating (for uncommon procedures, in depth/complicated procedures, and specific findings), along with the option of typing in their procedural patient specific data in our user-friendly application.