Be Clear when Communicating with a Provider
Listen carefully and articulate your intentions clearly for better patient care, documentation, and reimbursement.
By Lara Heishman, CPC, CEMC, AAPC Fellow
Clarity is instrumental to effective communication. Let’s consider what can go wrong when your communication with providers is unclear, and what you can do to be sure your message is heard.
When Bad Communication Gets the Better of Us
Scenario 1: The physician you work for asks you to provide a code for neck pain. You suggest ICD-10 code M54.2 Cervicalgia. Several months later, your practice manager comes to you with a stack of denials for trigger point injections. When the documentation is reviewed, it’s discovered many of the patients had a presenting symptom of neck pain; however, by the end of the visits the physician concluded the patients had cervical enthesopathy, fibromyalgia, myositis, or some other definitive underlying etiology.
Following your brief encounter with the physician months ago, you realize he’s been coding only the presenting neck pain for all his subsequent trigger point injections in the cervical region.
Lesson Learned: Reporting an incorrect code, even by mistake, could mean the difference between reimbursement and denial. This example is a pretty benign communication blunder, but imagine the consequences of a riskier mistake — one that could affect a patient’s health. Providers have a huge responsibility to ensure clear, concise communication with every patient at every visit. That doesn’t mean coders or other non-clinical staff get a pass.
Scenario 2: I had an experience where I shared audit results with a pediatric oncologist, which went horribly wrong — and at lightning speed — due to a lack of intuitive and sensitive communication on my part.
I was a newer auditor, focused solely on making sure this provider changed his coding to better match his documentation. This provider essentially failed the audit. We discussed how his patients couldn’t possibly be high complexity at every single visit because, ultimately, he is only addressing one problem. If you’re at all familiar with the rules of medical decision-making, one established problem, whether stable or worsening, doesn’t support high overall complexity.
Rather than heed my “expertise,” this provider was furious. How could kids fighting cancer not be considered severe enough to report the highest evaluation and management (E/M) levels? I felt overwhelmed, and misunderstood — and worse, the meeting was a waste of the provider’s already limited time.
Lesson Learned: To make positive change, you must first gain a common understanding with your physician partners. This comes down to some simple communication principles.
Ask Questions at the Beginning and the End
A clinician should be a partner in coding, sometimes providing vital clarification to the gray areas where medicine and codes don’t align. It’s important to avoid going into a discussion with preconceived notions. Rather than make assumptions based on coding or documentation errors, ask clarifying and open-ended questions to gain a better understanding of the clinical picture. Don’t allow an intimidating set of credentials make you feel like you must prove yourself; the culmination of a provider’s experience and your own expertise is necessary to achieve success in coding. Continue asking relevant questions of the provider throughout the conversation.
Be sure you understand the whole picture, and that the provider understands you. Questions such as, “Do you know what I mean?” and “Does that make sense?” can seem condescending, or make it seem as if you are bored with the conversation. Questions such as, “Does this align with your clinic workflow?” and “Would a coding tip sheet be helpful?” tell the provider your goal is to support proper coding and documentation.
Listen to the Provider
A big part of communicating well is responding appropriately to what someone else says. This means you must listen carefully to understand everything they tell you. If you are distracted, possibly by thinking of your answer before the person has finished asking the question, you may respond inappropriately. Not only can that make someone feel unheard, it could also call into question your credibility.
Listening with your eyes is just as helpful as listening with your ears. By watching for cues in body language, you can more readily ascertain how the provider is receiving your message, and then adapt accordingly. Furrowed brows, for example, may indicate that the other person is trying to understand your point but, perhaps, is not fully succeeding. If you notice these small changes, ask questions and modify your communication style to help the provider understand.
Speak a Common Language
Most coders are cut from similar molds. We love numbers, acronyms, and buzz words. Too much of these, however, and you’re likely to lose a provider’s interest (or worse, the provider’s patience). Have you had a conversation with a provider that ended abruptly because the provider is suddenly busy? It could be that the information you shared didn’t seem relevant to the provider. Speaking a language the provider relates to could save both of you time and frustration.
Example: Two common omissions in initial inpatient documentation are family history and a full review of systems. These pieces of documentation are often missing because:
- The information is not clinically relevant for the problem;
- The information cannot be obtained by a patient who can’t communicate; or
- The billing provider is relying on a resident to document the visit.
Yet, initial inpatient visits may be complex, and the two highest level initial inpatient codes require a comprehensive history. Most providers may not know the differences in the documentation requirements for a detailed history versus a comprehensive history. The terms “detailed” and “comprehensive” are also subjective and have different meanings for different codes. For example, a comprehensive history for a subsequent inpatient visit does not require medical, family, or social history, at all. A comprehensive history for an initial inpatient visit, however, requires all three.
Lesson Learned: Rather than confuse a provider with varying meanings of the same words, let the provider know the exact documentation necessary to support the level billed (if medical necessity confirms the billed level was the correct level). If the complexity of decision-making is high, 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity may be plausible, so suggest that the provider ask a few additional related sign or symptom questions (if medically necessary to bolster the review of systems). Perhaps, obtaining a relevant family history could provide the missing components to support a more appropriate level of service. This is a clear message any provider will understand.
Many of us have hectic schedules, so it makes sense that we are distracted easily. A recent study, “Media Multitasking and Memory: Differences in Working Memory and Long-term Memory,” proved multi-tasking decreases your ability to retain and recall information from memory. When multi-tasking, there are too many distractions to be present in the moment, and you can’t retain information that you aren’t fully present for. This is a great reason to follow up after discussing important coding and documentation guidelines, especially when a provider may be unfamiliar with the information.
Follow-up can come in different forms, depending on a few factors. Consider the learning preference of the provider. Perhaps an additional face-to-face meeting is better suited than an email summary. Consider also whether resources available to you and the provider are limited. If the original audit was performed by an outside agency, does the budget allow for a follow-up audit or should additional educational sessions be performed in-house?
The most successful documentation improvements happen incrementally, over time. An example was a provider who started an audit process with a wide array of documentation errors, and one at a time, turned them around. It took three audits, with subsequent educational sessions focused on just one or two of the errors, but the final audit reflected a perfect score. Alternatively, if you find yourself repeating yourself at meetings, consider changing the words you use to explain an error, or changing the clinical example. It can result in greater understanding.
Establish a personal connection, so your provider has a solid reason to listen to what you have to say. And be equally ready to soak in the knowledge and experiences your provider shares. In this way, you will be establishing a firm baseline from which any conversation is possible.
Be patient and keep trying. A good communicator is always evolving.
Lara Heishman, CPC, CEMC, AAPC Fellow, has a passion for education. She has more than a decade of experience, most recently creating and presenting specialized training programs for multi-specialty practices. Heishman has enjoyed various speaking engagements across the country, including HEALTHCON, and welcomes the challenge of understanding updated coding and documentation legislation. She is a member of the Charlotte, N.C., local chapter and previously served as president-elect and president of the Mooresville, N.C., local chapter.
Psychonomic Bulletin & Review, “Media Multitasking and Memory: Differences in
Working Memory and Long-term Memory” (April 2016, Volume 23, Issue 2, pp 483–490): www.ncbi.nlm.nih.gov/pmc/articles/PMC4733435/ https://link.springer.com/content/pdf/10.3758%2Fs13423-015-0907-3.pdf