November 13, 2013 | | Comments 2
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Tips for dealing with documentation challenges

The majority of respondents in our recent (unscientific) JustCoding poll identified physician documentation as their biggest concern heading into the ICD-10 transition.

TipsNo one should be surprised by that because we’ve been worried about (the lack of good) physician documentation for years. Our friends at the Association for Clinical Documentation Improvement Specialists (ACDIS) dedicate their professional lives to improving physician documentation.

Many on the HIM side are also worried about training physicians about ICD-10 and documentation. How do you get them to listen (and care)?

Here are some quick pointers I picked up from various speakers at the AHIMA Convention last month in Atlanta:

  • Physicians really want to hear from other physicians. And it helps if that physician is in the same specialty. Neurologists aren’t interested in hearing from plastic surgeons and cardiologists don’t care what orthopedists have to say.
  • Keep the information relevant to the physician’s specialty. Don’t talk to pulmonologists about gastrointestinal procedures.
  • Tell physicians specifically what they aren’t documenting. If they are already documenting laterality, don’t mention it during discussions about documentation improvement. If you spend time telling them they need to document something that is already in their notes, they may miss when you point out what isn’t in the documentation.
  • Give them concrete examples from their documentation. This takes a little bit of work, but it could pay off big time. Take the physician’s note, open the ICD-10 manual, and physically show them what information is in the documentation and what information the coders need.
  • Remind the physicians that ICD-10 is not going to change the way they treat patients. It’s not about the practice of medicine. We know they provide great care, we just want them to document that care.
  • Ask the physician if his or her documentation would pass muster in medical school. Would you accept this note from a resident?
  • Last, but probably most important—tell them why they should care. And don’t talk about money. They don’t care. They’re still getting paid based on CPT® codes for their services. Besides, financial gain should never be the main goal of documentation improvement. However, their documentation will affect their quality scores and their profile. So it really is in their best interests to clearly document how sick the patient is, what the physician was thinking, and how the physician treated the patient.

Have any other tips or ideas? Post them in the comments below.

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Michelle A. Leppert About the Author: Michelle A. Leppert, CPC, is a senior managing editor for JustCoding.com. JustCoding provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.

In addition, she writes and edits the HCPro publication, Briefings on Coding Compliance Strategies. Email her at mleppert@hcpro.com.

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  1. I do monthly provider audits and provide providers with an educational feedback memo that has copy and paste “snipping” samples of documentation issues. This gives them a visual of their own documentation integrity. Then I provide them the optimal documentation option.

    I also compare the previous month findings as I audit current month and share positive comments when they have achieved that documentation goal.

  2. I have created an environment to include physician’s as part of the solution to documentation issues and reinforce their role in the bigger picture (the ultimate patient care, quality of care, use of resources, severity of illness, ICD-10 specificity, etc). I have found that the majority of physicians want the patient record (and their documentation) to be as accurate and complete as possible and are willing to work toward a solution. Their suggestions into the process of how to get it done is invaluable since they are the experts of how the system works for them. These suggestions have been successfully implemented into our process for documentatation of great patient care. Having an active role allows the physicians to take ownership of these issues and solutions.

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