1. ©2012 TrustHCS Confidential Getting it Right: How to Improve Physician Documentation in Practice Deborah Robb, BSHA, CPC Director, Physician Services TrustHCS Lori Owens, RHIT, CCS Director, Operations Physician Services TrustHCS

2. ©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:

3. ©2012 TrustHCS Confidential 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

4. ©2012 TrustHCS Confidential 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.”

5. ©2012 TrustHCS Confidential 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

6. ©2012 TrustHCS Confidential 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

7. ©2012 TrustHCS Confidential 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

8. ©2012 TrustHCS Confidential 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

9. ©2012 TrustHCS Confidential ICD-10 Documentation Analysis

10. ©2012 TrustHCS Confidential 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.”

11. ©2012 TrustHCS Confidential 99213 99214 99215 Revenue Differences RVUGPCITOTAL Work RVU0.971.000$33.00 Non-Facility Practice Expense RVU1.100.851$31.85 Malpractice RVU0.071.023$2.44 Non-Facility Total RVU2.14$67.29 RVUGPCITOTAL Work RVU1.501.000$51.03 Non-Facility Practice Expense RVU1.540.851$44.59 Malpractice RVU0.101.023$3.48 Non-Facility Total RVU3.14$99.10 RVUGPCITOTAL Work RVU2.111.000$71.79 Non-Facility Practice Expense RVU1.950.851$56.46 Malpractice RVU0.141.023$4.87 Non-Facility Total RVU4.20$133.12

12. ©2012 TrustHCS Confidential 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

13. ©2012 TrustHCS Confidential 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

14. ©2012 TrustHCS Confidential 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

15. ©2012 TrustHCS Confidential 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

16. ©2012 TrustHCS Confidential When should we start? Orientation Active staff Training Program Implementation

17. ©2012 TrustHCS Confidential 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

18. ©2012 TrustHCS Confidential 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

19. ©2012 TrustHCS Confidential Starting a Training Program Who should be involved? Location Specific Rural Areas General Session Breakout Sessions Specialty Specific Large Groups of Specialties

20. ©2012 TrustHCS Confidential 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

21. ©2012 TrustHCS Confidential Most common for family practice Provide education related to the types of patients seen frequently Start off with the top 20 diagnoses Location Specific

22. ©2012 TrustHCS Confidential Specific training by specialty Identify gaps: Specificity? Laterality? Acuity? Location? Progression to ICD-10-CM

23. ©2012 TrustHCS Confidential Evaluate training success! Auditing scores Complete documentation Clean claims Conclusion