Providers - Now is the Time to Change How We Document!Andrew B. Maigur MD, CHCQM PHYADV, CMPC While most of us rang in the New Year either with friends and family or caring for our patients at the bedside something changed in the regulatory world of healthcare with considerable impact on provider revenue. As of January 1, 2023, CMS’ (Centers for Medicare and Medicaid Services) OPPS (Outpatient Prospective Payment System) 2023 Final Rule went into effect. To reduce the administrative burden on providers CMS revised the E&M (Evaluation & Management) coding guidelines for Inpatient Providers. Substantial changes were made, including the elimination of observation E&M codes and combining inpatient and observation hospital E&M services into a single existing E&M code set. Understandably this created a great deal of confusion with providers assuming that observation status had now been abolished. I would like to clarify that observation status has not been eliminated, the 2-midnight rule is still in effect for Medicare patients and commercial payers will continue to use commercial criteria to determine admission status. Physician Advisors now is your chance to educate and to advocate for tweaks in documentation practices. A tremendous change for the inpatient E&M code set is the elimination of required elements for the HPI (History of Presenting Illness), ROS (review of systems), family history, social history, PE (Physical Exam) and the bulk of the weight now falls on MDM (medical decision-making). Now more than ever medical necessity documentation will play a vital role. Clearly spelling out the reason for hospitalization, enumerating potential medical risk to the patient if the condition were not treated in the hospital and supporting daily hospitalization with medical necessity, adds to the complexity of MDM. CDI (Clinical Documentation Integrity) positively impacts MDM, e.g., symptoms like "altered mental status" versus a diagnosis of "Acute Metabolic Encephalopathy" influences the complexity and severity. Document using descriptive words such as acute, chronic, severe, moderate etc. Link diagnosis to possible etiologies, document treatment options, comorbidities that affect treatment & their clinical impact on patient outcomes. Avoid using generic words like "stable" which is subjective rather use "improving but not at baseline" indicates the need for continued care in the hospital. Collaborate with the CDI & Coding teams to enhance your documentation, CDI/Coding queries are not meant to question your clinical judgment but rather to improve the specificity of your documentation which in return impacts your E&M coding. Now is also the time to address the copy and paste (C&P) and copy forward functionality in the EMR (Electronic Medical Record). While we all agree copy and paste is an efficient time saving tool, when not used compliantly can lead to inaccuracies, misrepresentation, and potential regulatory and medico-legal challenges. CMS concurs stating, "healthcare professionals have stated that copying and pasting notes can be appropriate and eliminate the need to create every part of a note and reinterview patients about their medical history. However, HHS–OIG (The US Department of Health and Human Services Office of Inspector General) identifies illegitimate use of cut and paste record cloning as a problem." In the new E&M guidelines C&P material when not updated/edited to accurately reflect the care provided during the encounter would not necessarily count toward medical decision making. Also, C&P of test results without any analysis demonstrating clinical significance does not contribute towards level of data to review and analyze. Rather than copying forward a physical exam, document a fresh medically necessary exam with pertinent findings for each patient encounter. These guideline changes further bolster efforts to curb note bloat. Links that pull in historical labs, imaging test results and procedure notes do not contribute towards MDM. Simply declaring the specific test results, medical records reviewed and the clinical significance to the current episode of care would be sufficient. Several health systems have leveraged technology within the EMR and created specialty specific standardized note templates. Using the functionality of hyperlinks, the provider can access distinct parts of the EMR from their note without pulling in extraneous data into the note, while keeping their note open. The ability to create disappearing tips with rule-based decision-support serves as real time reminders to address documentation deficiencies that impact quality metrics and reduce the number of Coding and CDI Queries thus limiting interruptions in workflows. The medical record serves as a communication/hand off tool between providers and other members of the care team and is also accessible to our patients, health-insurance payers, auditors, attorneys etc. As physician advisors we have a unique opportunity to collaborate with our Informatics, CDI, Coding & HIM departments to effect change. Now more than ever we as a physician advisor community have a responsibility to educate and inform our provider colleagues, so feel free to share this article with your medical staff. References: https://www.ama-assn.org/practice-management/cpt/what-physicians-need-know-about-em-code-changes-coming-jan-1 Dr. Maigur is System Director of the Premier Health Physician Advisor Program. |