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?

Coders Relax: Your Job is Secure

In this article from For The Record Magazine, Julian Schaeffer explores and dispels coders’ concern that Computer Assisted Coding (CAC) will eliminate their role in healthcare.  With technology advancing more and more each day, it does make some of us wonder, “Will technology eliminate my role within my company/industry?”.

 

Coding is a very complex, ever-changing aspect of the healthcare industry. To keep up with all of the regulatory changes on top of the industry demands, we’ve got to engage and embrace the assistance of technology or we’ll never be on top.

 

With new diseases and procedures to learn each year, continuously changing regulatory requirements to comply with, and IT to implement, coders are likely to welcome any technology that promises to leave their jobs a little less complicated. But computer-assisted coding (CAC) has some in the industry wondering if the technology could completely wash out the need for coders’ human touch.

 

The concern is somewhat understandable, yet totally unnecessary. With the mystery of new technology many coders may feel threatened by the new advances and even the efficiencies that new technology brings to their workflow. But whether we like it or not, technology is advancing more and more into our jobs, so we better embrace it….along with all the changes, efficiencies and advances it brings.

 

Point of Clarification: This is a great article about coders feeling threatened by technology, namely CAC (Computer Assisted Coding). ComplyMD is NOT a CAC – ComplyMD, in respect to CAC, takes the concept one step further, and puts the power of correct documentation into the hands of the physicians. By correct documentation, I mean that ComplyMD actually enables (and somewhat makes) the physician document in a coder’s language. That way the coder does not spend time deciphering “clinical slang vs. code book language”; their time is spent ensuring that the physicians documented what they did accurately and correctly. So, like a CAC, ComplyMD enables the coder to have more of an “auditor” role, as opposed to a “code assignment and physician mind reader” role.

Overcoding, Undercoding and Inadequate Documentation – How Can They Be Avoided?

In response to the question “What percentage of physicians, in your experience, exhibit overcoding or undercoding patterns?”, John W. McDaniel answers:

“We work with hundreds of physician practices each year, and probably 80% of all the doctors with whom we work undercode. About 15% overcode, and about 5% code accurately. Even those that seem to overcode may not in fact be overcoding, because chart audits will reveal that the real underlying problem is inadequate documentation to support the appropriate code.”

Physician Practice Options, September 2000. “Practice Management Expert Highlights the Importance of Coding Compliance”

 

As we can see, a look into a physician practice’s coding records will reveal a lot about the actual accuracy of their coding. Now, please note that this does not say “coders are doing a poor job of coding” – by no means is this laying the issue on the coders shoulders. What this reveals is that physicians are the ones who are doing a poor job of documenting. Inadequate documentation is a huge issue. Erroneous documentation is another no-no. LATE documentation can even cause issues and discrepancies in a facility’s ability to code accurately.

 

Good Documentation Means Quality Patient Care

“Too often, doctors are so focused on patient care they sometimes forget to focus on coding and documentation. But if they do not, they won’t get paid for the work they do. Some physicians think documentation takes time away from patient care and that compliant coding reflects nothing about the quality of attention patients receive. These statements are just not true. Good documentation is critically important to patient care.”

Coding Corner. March 2007

Good documentation is not only critically important to patient care, it actually reflects quality patient care. Physicians must ensure accurate documentation of the patient encounter if they want to receive accurate reimbursement…..we know that. But physicians must realize that properly documenting all of the diagnostic and procedural data for a patient actually helps the patient understand their condition and helps their insurance company know more about their patient.

How To Avoid Careless Coding: Proper Documentation

“Careless coding jeopardizes reimbursement, and can also lead to fraud and abuse issues. One of the most common mistakes results from poor OP report documentation. And, another involves miscoding procedures due to misunderstanding of the correct coding initiatives edits.”

“Avoid The Four Most Common & Costly Coding Mistakes” Ambulatory Surgery Compliance & Reimbursement Insider. May 2007

Careless coding is not always the direct result of the coders’ mistakes, but rather an error in the physician’s documentation. Basically, physicians and coders speak two different languages – coders speak code-book language and physicians speak clinical language. One would assume that code-book language would rightly align with clinical language; however, that is not the case in the healthcare industry. With such a vast language barrier, how can we expect coders to make accurate decisions of assigning codes when the physician documentation does not match the code-book language they’re required to speak for accurate, compliant documents sent to their third-party payers?

Should Doctors Get Bonuses? Should they be rewarded for ‘good work’?

This is a great article from Time (also featured on CNN Headline News) that looks at CMS’s Pay-for-Performance program efforts. The title “Should Doctors Get Bonuses?” prompts many to think, “Don’t they already get paid enough!” Well, what most of us don’t realize is that, according to the Journal of the American College of Surgeons (January 2008), ‘Projections are that payment rates (for physicians) will decrease by an average of 5% each year for at least the next 9 years, resulting in reductions of as much as 40% by 2015.’ (Physician, do you realize this?) So, what do we think? I say, SURE, reward physicians for good performance. Now, the real question will be HOW will they gather correct information and documentation to prove their performance? You’ll find out………through a system such as ComplyMD.

In the article, they point out that,

“Corporate America has long doled out bonuses to employees who do the best work. Such pay-for-performance programs have only recently caught on in the health care industry, but caught on they have — more than half of U.S. health plans, including Medicare, report offering some type of incentive pay to doctors and hospitals for meeting certain basic standards of care…..”

Well stated. If the rest of corporate America is rewarding employees for good work performance, why not do so in healthcare? And, even more so. Physicians are taking care of people everyday, and peoples’ lives are at stake? Would we not want them to be on some sort of incentive program? YES, we all think that ‘ideally’ every physician in America should take the 100% utmost care of their patients. And many of them do. Yet we must remember, physicians are humans and think like most of us as well – they’d like a little financial pat on the back, just like the rest of us in corporate America.

“In the absence of systematic reform, many insurers have turned to pay-for-performance programs to try to improve quality of care, and cut costs along the way. Early efforts have shown positive signs. In the first three years of an ongoing pay-for-performance demonstration project led by the Centers for Medicare and Medicaid…..findings released in January, researchers following the project concluded that quality scores in the five measured clinical areas had improved on average 17%, and costs had been reduced $1,000 per patient on average. Researchers estimated that if all American hospitals adopted similar bonus schemes, we could save 70,000 patient lives per year and $4.5 billion in hospital costs annually.”

So this data proves that P4P can work. Well, how can we attempt to save 70,000 patient lives per year and $4.5 billion in hospital costs annually in American hospitals? Yes, through P4P initiatives. But HOW will they gather more information to prove their performance rates are up? The issue is documentation: PHYSICIANS MUST PROVIDE PROPER DOCUMENTATION IN ORDER TO DOCUMENT THEIR GOOD PERFORMANCE. Will their coder be able to provide proper documentation for increased performance? No….the coder is not in the room during the procedure to know of a performance increase. The physician and his/her staff MUST document well in order to warrant their pay-for-performance.

And physicians must have the TOOLS to document well… an 8½ x 11 “Remember to Document ‘X Y & Z’ Diagnoses on Your Patients!” stuck to the wall in the physician’s lounge is not a tool to help doctors document well. Give them an easy to use product (ComplyMD) that will enable them to capture appropriate data to document appropriate diagnostic and procedural data to warrant accurate reimbursement and rewards for performance.