Practice Management Alert

Organize and then communicate the needs of your other team members.

Summer is coming, and for some practices and organizations that can mean an influx of new providers joining the team. Whether your organization has regular turnover or is small enough that a new provider is a big change, figuring out how to set a strong foundation for your new colleague is important — and if you aren’t a clinician yourself, the process is, perhaps, even more fraught.

Use these tips to communicate the nuts and bolts of some coding realities to clinicians.

Do the Planning

Getting organized makes every point in the process smoother; you’ll know exactly what information you need to cover with a new provider.

One way to get organized is through using a template for all onboarding, says Victoria Moll, CPC, COC, CPMA, CRC, CPRC, CEO of Contempo Coding LLC in Fleetwood, Pennsylvania. A template will help you make sure that you don’t forget any crucial information. Think of the template as including items you always go over anyway.

You know you don’t need to go over anything involving patient care, since that’s what clinicians are trained to do, but covering some aspects of documentation and other sort of paperwork is important. If your office has a template for inputting patient information or other form of electronic health records (EHR), make sure your clinician knows the ins and outs of how to best report that documentation. Highlight how problematic it is to copy and paste information between patients or between patient visits.

Cover what’s medically appropriate and document that, but you don’t need to provide a complete review of systems (ROS) for every patient for billing purposes, Moll says.

Concentrate on documentation requirements, common errors, expectations from other staff — as far as what information other team members need to do their own jobs — and who the physician should go to with any questions.

“Don’t make your doctor be a coder,” she says.

Frame Pertinent Info Around Provider’s Perspective

“What is important to you when auditing a note is not what’s important to a provider,” says Shannon DeConda, CPC, CPMA, CEMA, CMSCS, president of NAMAS and partner at DoctorsManagement, in a 2021 HEALTHCON session.

With this in mind, you should focus on the absolute necessities of what providers need to know about documentation necessities like the pertinent aspects of evaluation and management (E/M) services — and communicate the pertinent knowledge by framing it around patient care.

Remember, a provider’s job is patient care — “documentation validates the care; we must always remember that this is their perception,” DeConda says.

Make Audits Work for Everyone

Audits conducted by one’s own practice can be a useful tool for everyone for figuring out what needs work or even what requires better communication.

As you onboard new providers, frame audits as a regular means of checking in. Decide — and tell — them how many audits you will do, within which timeframe.