Briefing: Improving Provider Documentation Date: 22 Mar 2007 Time: 1000 - 1050

1. Briefing: Improving Provider Documentation Date: 22 Mar 2007 Time: 1000 - 1050

2. Objectives This presentation will focus on the following: • The purpose of the patient record • Why good documentation is important • Documentation and communication tips • Searching for resources and support information • Developing a provider query process • AHLTA and CCE impact

3. Introduction • Proper and complete documentation plays a crucial function in patient overall care. • Good documentation can help avoid many future potential problems with: • continuity of care, • referrals/consults, • unnecessary rework • legal considerations • medical necessity • Electronic documentation has great legibility! • Documentation tells a story

4. Introduction - Continued • Very few providers or ancillary staff say that they enjoy writing documentation. • “Documentation is for medical students. I’ve been practicing for 25 years and I know what I’m doing.” • Challenges to good documentation: • Complete documentation is time-consuming • Provider understanding of what to document to support reported codes • Feeling like documentation takes away from primary role of taking care of the patient • Difficulty managing and understanding the changing IT requirements

5. Purpose of the Patient Record • Facilitate planning • Continuity of care and treatment • A communication tool • A business and legal record • Review for utilization and justification for future services • Medical Management (Case Mgmt, Utilization Mgmt, Disease Mgmt) • Support medical necessity

6. Why Documentation is Important • Medical record documentation is used for a multitude of purposes, including: • Serving as a means of communication between the physician and the other members of the healthcare team • A basis for evaluating the adequacy and appropriateness of patient care • Providing data to support billing • Assisting in protecting the legal interests of patients, healthcare professionals, and healthcare facilities • Providing clinical data for research and education • Make appropriate decisions regarding healthcare policies, delivery systems, funding, expansion, and education

7. Quality of Documentation • Without question, quality of care is more likely to be ensured when medical records are maintained in a fully professional manner. • A good litmus test to evaluate whether a patient's medical record is a satisfactory clinical document is to answer the following question: "If another provider had to step in to treat the patient, does the documentation provide sufficient information for the seamless delivery of services to the patient?“

8. Interesting questions • Question: With “hybrid” documentation and records existing in AHLTA and a paper record, what is the legal record? • Another question: With the code set existing in AHLTA and transferred to ADM, what is the legal code set if the codes are altered in ADM and not AHLTA?

9. Documentation • Accurate and pertinent documentation will: • Improve patient care • Support case mix (complexity and severity) • Support code sets for billing • Improve data quality for research and analysis • Create seamless clinical communications • Whether handwritten, electronic, or a combination of both, improvements to enhance and capture documentation elements often requires coding professionals to be key partners in MTF initiatives and policy making.

10. Tips for the Trade • Be careful-AHLTA auto-cite can be dangerous • Source MCM Section 15501 Subject Evaluation and Management Service Codes - General (Codes 99201-99499) • Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

11. More Tips Documentation for Consults • Request • Render (the service) • Report • AHLTA “auto-reports” encounter to referring provider, regardless of referral or consult Documentation for T- cons • Must contain evidence of medical decision making by a provider • Count if privileged; non-count for non-privileged • Must show patient - provider interaction • http://www.acponline.org/hpp/tel_care.pdf

12. More Tips Documentation for Procedures • Pre-operative diagnosis • Post-operative diagnosis • Name of Procedure • Date of Procedure • Type of anesthesia (if any) • Indications • Findings • Detailed description of procedure • Condition of patient upon completion • Provider Signature

13. More Tips • Simply Selecting the name and associated CPT/HCPCS code for the procedure in AHLTA does NOT constitutes enough documentation to support coding the procedure • Documentation must detail the procedure no matter how minor/routine the procedure is • Includes injections (location, dosage, med, etc) • Chronic conditions in HPI • Include status, not just listing condition • For 1997 DG, status 3 chronic or inactive conditions qualifies for extended HPI

14. Bringing in AHLTA Per DoD GL’s 3.1 Chief Complaint If the chief complaint is NOT what the appointment clerk or nurse/tech entered, (e.g., patient told clerk the appointment was for abdominal pain, but when the patient met the provider, the patient expressed concerns about an STD), the CORRECT chief complaint must be documented.

15. AHLTA Continued Only those parts of the HPI that are actually documented or referenced by the provider may be used in calculating the level of the encounter. When support staff document HPI information, the provider must take ownership of that documentation. Failure to do so will result in the AHLTA E&M calculator erroneously including the support staff HPI documentation in the E&M code calculation. To certify that the provider reviewed the information documented by others, there must be a notation supplementing or confirming the review.

16. AHLTA taking ownership In AHLTA, Providers can take ownership of the documentation and modify it. When the provider takes ownership of the nurse/tech documentation, these elements are considered the provider’s documentation and are included in the calculation of the E&M code. ROS and PFSH documented by support staff, if the provider does NOT take documentation ownership, the provider must re-document the ROS and PFSH.

17. AHLTA and Time Per DoD GL 3.1.5.1 • Time is NOT a dominant factor for assigning the appropriate E&M code in MOSTscenarios. • Time is a determining factor when counseling or coordination of care consumes more than 50 percent of the time a provider spends face-to-face with the patient, the family, or both. • EXTENT of counseling/CoC documentation increases with time and subsequent E/M level • Documentation must indicate (Per DoD GL 3.1.5.2): • Why the additional time was necessary, • What occurred during that time, and • How much time was spent (“dominated by”)

18. Resources and Support Information • www.codecorrect.com • www.aafp.org • www.emuniversity.com • http://www.usafp.org/CHCS-II-AHLTA-Information-FAQs.htm#837_HowTos • AAPC and AHIMA websites • www.donself.com • AAPC “Coders’ Resource Handbook”

19. Developing the Query Process • Compliance Plan provisions • Clinical documentation improvement program • Forming a work group • Organizational leadership • Provider champion(s) • AHLTA trainer • Data Quality • Coding/Auditing professionals • Analyze workflow processes • Develop alternate query processes • Analyzing documentation problems • Deciding priorities and approach

20. Developing the Query Process • Priorities • Incomplete or contradictory documentation • Incomplete specificity of documentation • AHLTA challenges • Establish the framework for improvement program • Teams designated to clinics and/or specific areas identified for improvement • Most success when leadership commits to and supports the program-HIGH VISIBILITY • Leads to accurate RVU capture • RVUs may improve in some clinics • RVUs may decrease in some clinics • Use CCE to query and track • Use online tracking/performance tools

21. CCE Queries Ways to query for incomplete documentation: • Query form • Email • Directly (in person) • Remember AHLTA is not fool-proof, the program works in conjunction with coders. It cannot read free-text and occasionally will count items that aren’t supported by the documentation. AHLTA should be considered an aid in increasing both accuracy and productivity! • Web search for query forms • Network with other professionals • HIM publications

22. Summary Expectations of Coding Professionals • The AHIMA Code of Ethics sets forth ethical principles for the HIM profession. • HIM professionals are responsible for maintaining and promoting ethical practices. • This Code of Ethics states, in part: "Health information management professionals promote high standards for health information management practice, education, and research." • Another standard in this code states, "Health information management professionals strive to provide accurate and timely information." Data accuracy and integrity are fundamental values of HIM • Employing practices that produce complete, accurate, and timely information to meet the health and related needs of individuals • Following the guidelines set forth in the organization's compliance plan for reporting improper preparation, alteration, or suppression of information or data by others • Not participating in any improper preparation, alteration, or suppression of health record information or other organization data

23. Q&A Questions? Answers?