By: David Klein, CPC, CHC
Recently there has been a large increase in post-payment reviews, audits and an increased emphasis on correct coding and documentation. Now, with Medicare struggling to survive, there is the potential for even more scrutiny. Many providers are questioning their documentation and not sure what carriers are looking for. The question often becomes, what is the best most efficient way to document and protect my Practice?
Obviously to protect your Practice, proper documentation is critical. However, many providers aren't sure what "proper" means and even if they did, they aren't sure how to implement it into their Practice. General instruction on how to document is nice, but again, many providers look at "documentation instruction" and ask themselves, "how does work it in my practice?" Often, providers feel that today's documentation requirements are so complex and difficult that it is simply not worth the effort and they begin to ask themselves "maybe I should go all cash?"
While going cash for some may work, for most it's not a viable option. So how does a provider satisfy the complex requirements for documenting and still have time to see enough patients to stay in business? Answer: Simplify the process.
While documentation is a necessary evil, it does not have to be overly complex or terribly difficult to do. The key to fast, comprehensive and compelling documentation is to think of it like you are writing a story - it is the story of how and why you treated your patients. If your story says the same thing over and over again it's not going to be a very good story. If your story only includes a recap of what you did, again, not a very compelling story. A good story will often have ups and downs, highs and lows. It's the very unpredictability of it that makes for compelling and "proper" documentation.
Of course before you write a story you have to do an outline of the story, this is will be your treatment plan (otherwise known as a care plan) and it is one of the most critical aspects to telling a good story. The first step is for the Provider to complete a history and examination and based on those findings, the care plan is then developed. The plan should map out what, why, where and for how long, identify risk factors and show how the Provider thinks the care will progress over time. It should be noted that Medicare, state boards, private insurance carriers and almost all other carriers require care plans. One incentive to creating detailed care plans with specific goals, sites and rationales for services is that you can reference it in your daily notes, saving valuable time and effort in documenting. For example, if you identify in your care plan that you will perform manual therapy consisting of trigger point therapy and myofascial release to the upper trapezius muscle. You can simply reference that in your notes, "Manual therapy provided for 15 minutes, as per care plan."
Once a care plan has been developed telling the story becomes a matter of recording each date of service like a chapter in a book. Chapter one is the prologue, everything else is based on it and each date of service is simply a comparison to the previous visit. Re-evaluations are like major chapters in the book and should focus on comparing results of previous evaluations. When providing care, the Practice should make sure to follow the care plan as close as possible. Remember, there will definitely be positive and negative outcomes to the story and that's ok – again, this is what makes the story compelling.
Below is a list of some key components that should be included in the story:
- Establish a starting point – the baseline. All other Dates of service should be a comparison of the baseline.
- How is the patient doing in comparison to the last visit? >> Measure your results
- Much more than a simple "Pain" scale >> multiple conditions, multiple scales, e.g. pain at rest and pain with motion...
- How does the care relate to ADL's? What makes it better/worse?
- Be Specific >> "Subluxation levels: C2,C3, L4, L5"
- Don't simply repeat positive tests >> less is sometimes more.
- Include specific sites / areas treated and specific services provided >> "trigger point therapy" vs. "manual therapy"
Utilizing an EHR system can be a great way to help speed up and simplify the process, however make sure the program allows you to tell an accurate story and include the necessary items. EHR systems that incorporate care plans and help you to follow it are critical to satisfying state, federal and local payer rules. Obviously, canned repetitive notes are not good but neither is complete "randomization" of text as it tends to tell individual stories not THE story and these programs are very easy to spot.
Obviously, this process does not happen overnight. The threat of audit and post payment review can be scary. With the ever changing rules and requirements, providers can feel overwhelmed and some even begin to question their commitment to the profession. However, telling the right story is one of the sure things you can do to take a proactive approach before you find yourself faced with and audit.
David Klein, CPC, CHC, ANJC coding and compliance consultant is the co-founder of PayDC. He is a certified professional coder through the American Academy of Professional Coders (AAPC), and is certified in healthcare compliance through the Health Care Compliance Board (HCCB). His expertise in coding and compliance consulting stretches over twenty years in the healthcare arena. He has provided training and education to hundreds of healthcare providers in both one-on-one and group settings. He was the past operations and billing director for a 36 office clinic and is the Founder and President of DK Coding & Compliance, Inc. a health care consulting firm that focuses on audit defense, education, compliance and reimbursement issues.
