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Documentation and coding tools

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By Christopher Guadagnino, Ph.D

In the wake of HCFA’s controversial Evaluation and Management (E&M) documentation guidelines and their indefinite implementation delay, physicians have been given ample reason to be concerned about their documentation and coding habits. Government billing audits of teaching hospitals have grown in number and the Office of Inspector General said it is hiring more agents to gear up for audits of as many as one-third of all physician offices. Penalties for coding errors can be substantial and findings of fraud can carry criminal as well as civil penalties.

Meanwhile, managed care penetration brings more capitated contracts and an increasing number of patient visits per day, placing more constraints on a physician’s ability to document patient visits efficiently and accurately.

An assortment of products and services are available to physicians to help them manage increasingly detailed requirements of clinical documentation and coding, ranging from unstructured pen and paper notes to paper template forms to computer software-based systems. Basic software systems facilitate either documentation or coding and are not networked to other databases. More robust software and hardware systems perform both documentation and coding, are networked to other databases and physician offices, and are augmented with additional features such as the ability to prescribe medications online.

Physicians need to examine the strengths and weaknesses of various documentation and coding systems and determine which is most appropriate for their practice setting. Documentation efficiency aside, one might also contemplate how useful these systems are to actual patient care.

Paper-based Systems

The simplest and perhaps most widespread method for documenting clinical aspects of a patient visit remains paper and pen, whereby the physician jots down what he or she regards as the salient information concerning the patient’s history, symptoms and treatment protocol. Payment coding is done subsequently by the physician or by hired professionals.

Another type of paper documentation involves specialty-specific templates for patient encounters. One such product, called the T-System, is offered by a company from Dallas, Texas and is designed specifically for emergency department patient encounters. The T-System is comprised of over 50 complaint-specific, customizable templates on which the physician circles positive history or physical exam findings, checks normal statements and places a backslash across words or phrases that represent pertinent negatives. The templates make use of detailed diagrams for given anatomical systems.

The company’s promotional brochure claims that the T-System templates greatly reduce time spent documenting a patient visit and can be coded twelve times faster than transcribed records. The company boasts that using the system can realize a $15 to $19 savings per patient on transcription costs, improved efficiency and improved reimbursement. The templates have been accepted by all categories of insurers, the company says, and have been explicitly approved by various Medicare carriers. The templates also contain prompts in the physical exam that address HCFA’s new “bulleted” items in the required systems and areas.

Paper-based diagnosis and procedure coding is usually done by physicians themselves, or by in-house staff or outsourced companies. Specialty-specific coding publications are readily available from the AMA, HCFA and specialty societies for that purpose. Companies such as Philadelphia’s Health Power Associates offer pocket reference cards with specialty-specific information about procedure coding.

Paper documentation and coding may expose physicians to the greatest risk of inadequate documentation in the event of a billing audit, as thoroughness of documentation is left to the physician’s professional discretion while auditors are inclined to apply the maxim, “If a procedure wasn’t documented, it didn’t occur.”

Conversely, unstructured paper and pen documentation imposes the least on the flow of communication between physician and patient, and offers the richest account of the physician’s actual though processes at the time of diagnosis, believes C. Richard Schott, M.D., FACC, past president of the Delaware County Medical Society and a member of the Pennsylvania delegation to the AMA. Requiring physicians to verbalize everything they do in the form of prescribed documentation templates imposes on the quality of patient care, even if it is expedited by technologies. “Data collectors would like us to record everything,” Schott says. “That’s not how patient care is done.”

Basic Software Systems

Computer software offers physicians the ability either to document or code using systematic templates on a desktop computer. The systems create “flat” databases that are not linked to other databases, but generally cost under $1000 and offer some useful capabilities not possible with paper-based systems.

Shared Medical Systems, a Malvern, Pennsylvania company, offers a product it calls Encounter, which is designed for primary care physicians in ambulatory office settings. The system allows them to review a patient’s clinical history, enter notes, prescribe medication and chart results. Clinical data can be entered directly into flow sheets and textual documentation is expedited by a customizable primary care knowledge base which supports family practice, internal medicine, pediatrics and ob/gyn physicians. This feature allows physicians to choose from a list of model templates for a particular encounter or create their own. For example, a company brochure explains, when a patient complains about abdominal pain, the knowledge base gives prompts for cardiac symptoms like diaphoresis and shortness of breath. When inputing medication prescriptions, the system issues electronic reminders and alerts for allergies, drug interactions and duplication.

Jeffrey Rosch, M.D., a solo allergist in Altoona, took an existing DOS-based program and modified it to create patient evaluation templates that allow him to document pieces of patient medical history and examination appropriate to his specialty. His modifications expanded the physical and history components of existing software to fit HCFA’s recent E&M guidelines and those detailed by the Joint Council of the American College of Allergists and the American Academy of Allergy.

His system has 11 networked work stations located in various intake and testing rooms at his practice. “My database allows me to take a patient’s history and acquire exam data in an organized way and readily print out referral letters to primary care doctors without handwriting problems,” Rosch says. “I can give information back to the patient in the same form as it goes to his or her primary doctor, so no re-interpretation is involved,” he adds. The timing of the patient visit is also captured as data by Rosch’s system.

Rosch enters diagnostic codes himself rather than with the aid of a program. “Since I enter it once, I am responsible for it. Besides, as a specialist, coding is not as much of a problem for me since the variability of my specific diagnoses are fewer,” he explains.

Software exists for ICD-9 and CPT coding, such as CodeMaster Express for Windows, a software product out of Santa Cruz, California that requires only a desktop PC to operate. The physician types in a few key terms for a procedure or diagnosis while the program displays prompts for additional modifiers and returns a list of codes in descending order of probable applicability, explains Jim Thompson, the company’s physician product sales representative in Pittsburgh. The program also offers guidelines to link diagnosis codes to procedure codes.

The program gives tips on how to use specific codes, e.g., it flags procedures that cannot be billed separately so that the physician knows he or she must bill them as a bundle, says Thompson. The program also allows the physician to enter notes on how individual payors prefer coding to be done for a given procedure or diagnosis, which will be displayed each time the physician codes that item, Thompson adds. That feature helps physicians code consistently, which is important to auditors, says Thompson. “Auditors look at systems like ours as a key part of a compliance plan,” he claims.

Basic documentation and coding software offers tangible gains for physicians, as it appears to be ready-made to satisfy payor criteria by encouraging extensive, systematic record keeping and consistent coding. “Physicians who are feeling safer by undercoding have opportunities to earn more revenue by coding appropriately—potentially in as many as 25 percent to 40 percent of physician practices,” observes Craig Kappel, health care consultant for Arthur Andersen LLP.

On the other hand, no documentation and coding approach is useful to a physician if the format of its data fields is not intuitive, notes Jim Blakeman, vice president of practice management, Health Care Business Resources. Many data systems require physicians to flip through templates or screens, a process which is unlikely to reflect the sequence of information gathered during an actual patient encounter, he suggests. As patients often give information in an unorganized fashion, a physician may have to modify his or her pattern of practice to interface efficiently with an online patient data system. One solution, says Rosch, is for a program to allow the physician to collect the information, then put it in the right place later.

Physicians using software must beware that their computerized templates don’t turn out cookie-cutter patient records, warns Peggy Pugh, R.N., CPC, of Pittsburgh’s Geoffrey Stillson Associates. Medicare auditors look for duplication in patient records, and physicians using documentation and coding software may find it too easy to code patients similarly, she notes.

Documentation and coding systems can also be abused. Physicians may hire less skilled coders, since computer software makes coding that much simpler, acknowledges Codemaster’s Thompson, who adds that such a practice would be costly to a physician who winds up getting penalized for wrongful coding.

Patients could benefit from computerized patient databases. As capitated patient populations grow, outcomes data obtainable from online patient databases can be used to improve population-based medical practice, enhance patient education initiatives and lead to higher capitated reimbursement, observes Evelyn Eskin, president of Health Power Associates in Philadelphia. For example, a physician can use the database to target a letter to all of his or her asthmatics, or could inform the appropriate group of patients about a new treatment available for their specific medical condition, Eskin illustrates.

On the other hand, computerized documentation systems that input series of pre-programmed sentences tend to produce extremely bulky patient records that make it difficult to sort through the wheat and chaff to determine what the physician actually did, warns Schott. Since some software generates patient history and exam data at the push of buttons and by algorithm, one cannot tell the difference between a workup done by a physician assistant and one done by a physician, Schott adds. That, he says, may lead to more care delivered by nonphysicians and to the inability to determine the quality and judgment that went into the case.

Comprehensive Software and

Hardware Systems

Sophisticated computer systems exist that combine documentation and coding templates as well as link physician databases to each other and to hospital system databases.

A networked, online documentation system called EpicCare will soon be piloted at three physician practice sites within the University of Pennsylvania’s Clinical Care Associates (CCA), according to George Brenckle, Ph.D., Director of Clinical Applications Development. The point of care system will be used in ambulatory offices to capture notes and charting for storage and retrieval, for interface with laboratories and for prospective clinical outcomes review, says Brenckle.

Physicians using EpicCare enter patient information on a computer terminal in their office using templates they help to develop, tailored for various medical conditions. The system features a macro code whereby the computer recognizes abbreviated versions of specific clinical information and expands it to complete sentences, Brenckle explains. Voice recognition may be added to the system, expediting data entry even further, he notes.

CCA has pre-defined clinical ordering pathways which will offer the physician real-time clinical decision support rules for patients with given conditions, Brenckle says. For example, the system will incorporate alerts that require a certain diagnosis input for a certain treatment to be ordered.

EpicCare also informs the physician if a patient meets certain criteria to be billed for a certain level and can flag discrepancies by displaying a message like, “This is not a covered procedure. Do you want to order it anyway?” says Brenckle.

The University of Pittsburgh Medical Center (UPMC) is also implementing EpicCare in two of its physician practices, with plans to expand it throughout the system, notes Michael Gorin, M.D., a UPMC ophthalmologist.

EpicCare is well-received by auditors and has been approved by Penn’s compliance officers, Brenckle adds. “If you order a test that’s not covered, you need an indication that you told the patient that it is not a covered service. The system can prompt you to capture the patient’s consent,” Brenckle explains.

Broad application documentation and coding systems are available to independent or group physician practices as well, such as one by the Medic company called, AutoChart for Windows. The system uses a hand-held wireless touch screen which the physician can carry to different exam rooms and input patient data via RF transmission to a server for their computer system, explains Allan Winchester, the North Carolina company’s vice president of corporate development. The device uses real-time interaction, alerting the physician to a given room when a patient checks in, allowing the physician to call up the patient’s medical record and to input medical history and physical information by using a touch pen and template screens. Winchester says that 1000 physician practices in Pennsylvania currently use the system.

A string of text is entered into the patient record by tapping on appropriate buttons, such as “normal,” says Winchester. “Each tap on the template with the pen captures a discreet data element. The physician can tap out the medical record, requiring less time spent with the patient and with no transcription needed,” he adds. At the end of the visit, the system brings up a super bill that can be automatically transferred to the practice’s billing program, if the practice is so equipped. Winchester notes that AutoChart’s templates have been upgraded to meet HCFA’s new E&M guidelines.

A properly documented patient database network can facilitate communication between physicians and improve the accuracy and timeliness of patient care, believes Anthony V. Coletta, M.D., of Renaissance Medical Alliance, a 430-physician multispecialty IPA in southeastern Pennsylvania.

Coletta, a surgeon, contrasts the efficiency of an online electronic patient record-keeping system with the current system in which he receives limited patient information from a fax sent by the patient’s primary care doctor. “I may see a patient de novo with an insurance referral form. I don’t know the patient’s history, medication, when they had blood work, a chest X-ray or prior surgery, or I need to get information from the patient that is already recorded somewhere but hasn’t been formatted into a communicable database,” Coletta illustrates.

A clinical data repository for a large volume of patients, Coletta adds, could track a network’s outcomes for a given medical procedure and improve its clinical performance.

Online patient record systems can also capture contemporaneous data in critical care settings, tracking types and rates of medication and patient vital signs in real time, and that data can be analyzed retrospectively to improve treatment protocols, notes Blakeman.

The documentation and coding systems offer an opportunity for integrated health systems to track resource consumption and to be more disciplined in offering standardized care across large groups of physicians and patient populations, reining in costs attributed to varying levels of utilization, Kappel adds.

Further, by standardizing the information structure of patient records and reimbursement, the documentation and coding systems can lay the foundation for benchmark comparisons and enhance the drive for self-improvement among physicians, who could capture productivity and cost control data to demonstrate the value of their practice, notes Kappel.

However, Kappel acknowledges that many physicians say that standardization is not appropriate. Viewed in that light, resorting to the use of documentation and coding systems to meet payor requirements is a reactive step by physicians, he concedes, which could potentially accelerate the mining of physician productivity data by health systems to use as leverage against physicians.

Capital investment may be an obstacle for physicians considering a comprehensive software system for documentation and coding. While the more basic documentation-only or coding-only programs may cost under $1000, the more sophisticated systems that do both typically run tens of thousands of dollars, and networked systems can cost hundreds of thousands of dollars. Many physicians are limited by investments they’ve already made in their existing billing system. It may be a waste of money to invest in documentation and coding software when physicians don’t know which guidelines HCFA will ultimately hold them accountable to, notes Schott.

Tapping out prepackaged sets of scripts for patient records could be viewed as a loss of documentation quality, while a coding program that prompts a physician on what diagnoses are required for a Level 5 visit could facilitate inappropriate structuring of the patient visit to fit the billing level, warns Blakeman. Upcoding could thereby be more easily justified. An alternate view is that unscrupulous physicians can do that without the help of a computer program, and that the program is more likely to be used to ensure adequate documentation by prompting the physician to record enough detail for a diagnosis.

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