I attended a seminar last month where one of the presenters is a physician who was responsible for developing the practice's educational tools for teaching physicians documentation guidelines for compliance.
The presenter started by getting a good education in coding, and noted that the way we coders think is not the way the physician thinks.
We get out our audit tool and start at the beginning - with the history. But physicians see a patient and start their thinking process with the presenting problem.
So the presenter developed a "Simplified Table of Risk" which used ONLY the presenting problem section to identify the level of risk - Minimal, Low, Moderate or High. This made sense to physicians because they understood right away that if a patient presents with a runny nose and congestion they'll want to look at XYZ in terms of taking a history and examining the patient -vs.- a patient who presents with pneumonia where the physician will want to look at ABC in terms of taking a history and performing the exam.
The presenter further educated physicians on how the bullet points of history and exam tied to the "RISK" ...
The end result (it took some time for every physician in the practice to internalize this information) was documentation that was much more compliant and reflective of the level of service chosen.
A lot of the group in the seminar immediately questioned why they would leave out prescription meds in determining level of risk. The presenter emphasized that the simplified table was an educational tool - not an auditing tool. When auditing credit was given as per the auditing tool and used all the table of risk.
But the outcome after about a year, was that the audit showed a much higher level of compliance.
Hope that helps in thinking about these issues.
F Tessa Bartels, CPC, CPC-E/M
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