History of Documentation

“History of Documentation, A Coding Perspective”

The reasons behind the necessity of documentation include continuity of care and legal criteria, but one of the most over looked aspects is coding.   If you understand why this is important, it will give you a much better perspective on how your documentation needs to look.  Everyone uses the mantra, “If it wasn’t written down, it didn’t happen,” which is really irritating to me.  Where is the line between what you need to write and what you don’t?  If that mantra were true, I would have a 10 page note on EVERY patient visit.  That is absurd.  In today’s busying, regulation ridden environment, what we should be saying is, “Write down what matters to cover your *&^, get paid in timely manner and to show a covering doctor what to do.”  That is the truth. 

Mantras and one-liners are the mainstay of consultants, lectures and motivators.  Very few actually teach you the logic behind their quotes.  Just as someone who quotes a bible verse to elaborate!   A small percentage can actually do that, most can’t.  They rely on the teacher or consultant to have the answer and do not understand the philosophy/logic behind it.  The question then becomes, “How do I teach you the logic behind documentation without the silly mantra or scare tactics?”  We need to look at the coding profession for answers.    Although we are obligated to use CPT and ICD-9 codes to document patient care and obtain reimbursement, very few doctors really get what these mean and how to use them, not to mention that the AMA not only “maintains” those databases, but holds the copyright license to them as well.  

The medical profession has long since been tied to “documenting to code” concepts. Provider offices used to have a person or department that would review the doctor’s patient notes and would create a document for billing purposes which included CPT, any modifiers associated with the procedure(s), applicable E/M codes, V or E codes and the ICD-9 codes provided by the clinician.  The level of reimbursement and whether or not the doctor was accused of fraud was all based on what he/she documented.  It was read by the “coder/biller” and then sent away.  Once it left the office, that was it.  The doctor had to make sure it was documented properly.   I have many friends that manage medical offices or have been affiliated with billing/coding in private practice, hospital entities or in medical residency programs.  They will all say one thing, “DOCUMENTATION IS THE MOST IMPORTANT PROCESS in the entire equation.”  One of the most contentious of all meetings is one that puts documentation at the forefront with billers/coders taking one side and the provider taking the other.  It has brought down clinics…Can a professional coder look at your office notes and determine what codes to use without a billing slip or superbill?  For a new patient, can they apply the proper E/M code based on time and the criteria specific to each level?  Are the ICD-9 codes visible on EVERY patient encounter?  If the CPT code has a time component or part of a bilateral procedure, is that in plain sight to allow your office to get paid and defend the coding?  You get my point. 

With that being said, you need to take this perspective IMMEDIATELY.  The reason I am telling you this now is all about TRENDS.  The trends are all about using technology to enforce regulations and it is getting easier.  To make sure you get paid for what you do, like it or not, you are going to have to document at the highest possible level.  In order to stay in business, like it or not, you are going to have to get super efficient at that level of documentation.  There are only two options to do that.  One is to use a check box system and the other is involves electronic records.  If you need to, go listen to the following interviews in the MD Audio Library – members section:

Clinical Documentation
An interview with an electronic patient record expert – James Carlberg

Join me for a discussion with James Carlberg, a computer and electrical engineer who is an expert in electronic documentation.  This conversation is about the fundamentals of EMR (electronic medical records) and the emerging trends.  Learn why cloud computing is here to stay and how it is involved in our daily lives already.  Integration of an EMR is not as hard as you think and certainly not as expensive. 

Zair Fishkin PhD, MD
Adult and Pediatric Spine Surgery

Come listen to an interview with Dr. Fishkin, orthopaedic surgeon.  He gives a look inside the mind of a medical specialist. He shares with us why he refers to chiropractors and what he expects them to know and report.  Very few chiropractors get to listen in on a conversation like this. 

Change is happening and it is A LOT easier to do it slowly than all at once.  I am available to talk and help you through it, but you have to make the first step, to decide to do better.  Fast and effective documentation will help you to do the following and is worth the investment of time and energy.  This can be done inexpensively if you know where to look.   Streamline your practice and become bulletproof.  The following items are critical to modernizing your office:

– Touch your patient notes ONCE and increase speed of reimbursement

– Qualify your notes for reimbursement AND reporting to the MD

– Provide a means to “collect” with interest from the insurance carrier

– Provide a legally defensible billing process

– Have as much as 10 hours per week that will allow you to spend more time with your family or see more patients!{jcomments on}