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.

How Far Does Your Facility Go for Documentation Assurance?

In Hospital Case Management’s recent article “Does Your Documentation Assurance Program Stop Short?” (March 1,2009), the following quote caught our eye:

“If your documentation assurance program focuses on reimbursement alone, you’re not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it’s critical that the medical record accurately reflect the severity of illness and the services provided to your patients.”

If we really think about it, the quote above is totally true. Many facilities have implemented Documentation Assurance Programs, such as Clinical Documentation Improvement initiatives. And these programs oftentimes measure ‘success’ in terms of dollars and cents, rather than by quality documentation of severity of illness, continuity of care, level of acuity and risk of mortality.

“Many times, documentation specialists do a great job of picking up the complications/comorbidities (CCs) and major complications/cormorbidities (MCCs) but stop right there and miss the opportunity to add additional documentation, which will affect the drivers of acuity level and risk of mortality.”

Documentation Specialists are trained professionals who are taught to look for those CCs and MCCs. In an attempt to build the best DRG, they must capture these important conditions. But, they shouldn’t just stop when they’ve gotten to a certain DRG level. A good Documentation Specialist will not be focused on getting the patient into the highest paying DRG, but will be focused on painting the most comprehensive picture of the health of each patient.

This is exactly where ComplyMD comes in. In attempt to paint the most vivid picture of (1) the health of the patient and (2) the procedure(s) performed on the patient, we aid physicians and staff in capturing the most documentation about each patient encounter.

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?

Pay for Performance (P4P): Rich Data Creation

One of the quality initiatives set forth by Medicare is their Pay for Performance (also known as P4P) initiative. We have all heard about P4P. “The foundation of effective pay-for-performance initiatives is collaboration with providers and other stakeholders, to ensure that valid quality measures are used, that providers aren’t being pulled in conflicting directions, and that providers have support for achieving actual improvement.”

This is a great piece from a position paper on P4P: “The primary focus of the quality movement in health care should not be on “pay for” or “performance” based on limited measures, but rather on the patient. The American College of Physicians hopes to move the pay-for-performance debate forward with a patient-centered focus—one that puts the needs and interests of the patient first—as these programs evolve.”

I love that point that the American College of Physicians makes…basically, if we can make P4P about the patient and less about “payment” or “performance” then a lot of the fuss over P4P would be put to rest. With ComplyMD, physicians are in the business of rich data creation.

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.