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Developing Your Documentation and Corresponding Coding Program
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Practice managers and clinical managers often call documentation and coding “the silent monster.”

The outcomes of documentation and coding, which are important billing components, are hidden away in the patient’s medical record. They only raise their ugly head when some event such as a chart audit by Medicare, Medicaid, a vision-insurance plan, a third-party medical insurance or a lawsuit requires us to copy the chart and send it for review.

You make the copy and, lo and behold, you ask the ultimate question, “How could we have missed documenting that outcome?” or “There are not enough elements documented for that level of code,” or “There is inadequate or an incomplete chief complaint noted.”

Count yourself among the lucky few if you have not experienced the sinking feeling associated with review of an incomplete chart and accompanying coding. Consulting auditors usually find that clinical staff and practitioners do the work, but do not always get the information in the patient’s chart and, consequently, the resulting coding may match the work done, but does not match the documentation.

How then does one train staff to overcome these deficiencies? The old adage “an ounce of prevention is worth more than a pound of cure” is certainly applicable. Even in the best clinical practices, there will be an occasional failure in documentation and the corresponding coding. Auditors understand this and only look for documentation and coding patterns that suggest either negligence or fraud.

Here are a few recommendations that address prevention.

Implement a Practice of Documentation

Improving documentation and coding requires a culture change. Management, clinical staff and practitioners must all commit to accurate and careful documentation and coding. Remember, while the physician is ultimately responsible for accurate documentation and coding, the entire practice staff shares in this responsibility.

Audits can quickly turn a very profitable ophthalmology practice into a fiscal-affairs disaster as auditors use multipliers to calculate overcharges, and then add penalties and interest to define your reduction to future allowed charges. Practice managers and clinical coordinators will find that spending time up front on documentation and coding policy, process and training is much more productive than overcoming the outcome of a negative audit report.

Develop a Quality Assurance Program
A simple but effective quality-assurance program that requires regular chart audits will help you identify the clinical staff who need additional training. We suggest that you group your charts by each tech and practitioner. You may find that some of your clinical staff require more training. You may also find that your clinical staff do not scribe as completely when with a certain practitioner. Only a broad approach to quality assurance will uncover the specific weaknesses in your clinical documentation and matching coding program.

Define Written Policies for Documentation and Coding
A written policy defining documentation and matching coding is essential. There are volumes written on clinical documentation and coding. These resources are important, but they will not take the place of a defined policy that supports the appropriate documentation and coding culture of your practice.

Policy sets the expectation, defines goals and establishes strategies. Policy also defines how outcomes will be measured and prescribes the action to take if the outcomes are negative. Most importantly, policy defines how the process for documentation and corresponding coding will be implemented in the clinical setting.

Develop a Coding Process Flow Chart
Defining your work process may be best accomplished by developing a flow chart that includes explanatory notes for each step. Your process should reference an attached exhibit that outlines the documentation required for each level of eye code and E&M code.

Educating your staff is not a simple task. Clinical staff have different levels of experience and learning skills. Each requires a different level of training. The most effective tool to assist with documentation training is your exam sheet. Developing an exam sheet will prompt the clinical staff to capture required medical data. Most of all, a well-designed exam sheet will provide the practice manager or clinical coordinator a reference tool for training.

Design a Thorough Exam Sheet
Your exam sheet is best laid out in two sections. Section I documents clinical staff interaction with the patient and is completed prior to practitioner and patient interaction. This section must be designed to capture the review of systems, history of present illness and chief complaint. Discussion with the patient provides the elements associated with the visit that compliment documentation and drive coding levels.

Section II is the practitioner exam portion. A sample visit sheet (PDF 333K) is provided for your review.

Commit to Training Your Staff Thoroughly
Implementing your documentation and corresponding coding program is dependent upon the outcome of your training efforts. A classroom training program provides the best outcomes. Committing to Saturday training is never easy and is costly. However the time, money and effort will be well spent if it results in consistently improved documentation. And yes, practitioners should attend. As a follow up to your training day, one-on-one coaching may be necessary.

Keep in mind not everyone learns at the same rate and not everyone comes with the same level of experience. Mentoring is also an important part of the training process. Use your experienced clinical staff members to provide daily mentoring and coaching to younger and inexperienced staff.

If your practice hasn’t already done so, many practices will be looking to migrate to electronic health records (EHRs). EHR software will do more to improve documentation and coding than any manual training program could ever hope to accomplish. As powerful as the EHR has and will become, it will never replace the need for defining documentation and the matching coding culture, policy, process and training. The old adage — garbage in, garbage out — applies now and will continue to do so in the future.

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About the author: This article was adapted from the July 2010 issue of Techniques. It was originally written by Gordon Barlow, who has more than 50 years experience in health care management and is a co-practice manager at Augusta Eye Associates PLC, Fishersville, Va.

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