Physicians, Coders Working Together

Vol. 18 •Issue 9 • Page 12

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Physicians, Coders Working Together

EHRs support physician best practices in coding and documentation.

Leslie: It is great that we are seeing more and more successful implementations of EHRs in hospitals and physician practices. We are finally getting a chance to see some of the long-touted benefits of EHRs start to pay off, especially in the area of best practices in patient care and in documentation and coding.

Patty: That’s right Leslie. Financial incentives for physicians’ practices are giving a boost to EHR adoption. I am sure that physicians want to get the full bang for the buck so to speak. To see how it is playing out in the real world, let’s call on Kathy Johnson, our director of coding services at Care Communications to find out how doctors incorporate embedded tools in the EHR to improve their documentation and coding practices.

Kathy: Thanks for asking about that, Patty. With all the concern for accurate reimbursement and the Recovery Audit Contractor (RAC) program, which will move from pilot stage to full nation-wide implementation soon, it is imperative to have a good tool set in the EHR to support a more efficient and accurate documentation coding process in physician practices. To learn how embedding special alerts and coding tools has already helped physicians, we should talk with Dr. James M. Taylor, medical director, revenue cycle at Kaiser Permanente—Colorado Region.

Leslie: Great idea! They are a large practice, with 520,000 members in the plan, 800 providers and 18 medical facilities.

Kathy: Yes, and they generate about 10,000 outpatient claims a day. You can just imagine the financial impact of a good tool set to support best practices in coding and documentation.

Leslie: Dr. Taylor, thank you for joining us today. We would
like to discuss how the tools embedded in EHRs have supported better coding and documentation practices and how you led your organization through such a substantial change in processes.

Dr. Taylor: We started by understanding the issues that physicians have when they record diagnoses. For example, when a patient is seen who has had cancer and has finished treatment for the disease, the physician may still record a diagnosis of “breast cancer” on the record rather than “history of breast cancer.” The EHR makes it easy to carry a diagnosis over from one visit to another. From the physicians’ perspective they are seeing a cancer patient, but for accurate coding it should be recorded history of cancer. Now, with our EHR, when a physician enters breast cancer, a window pops up with the rules for “history of,” so the doctor will stop and think, “Oh, that’s right, this patient has finished treatment and I should record this as history of breast cancer.” We designed best practice alerts that among other things help clarify these often confusing documentation issues.

Kathy: How did you introduce the best practice alerts, and how did the physicians respond to them at the beginning?

Dr. Taylor: We did a pilot for 2 months. With no training other than a voicemail message, we turned on the diagnosis alerts features, and we have had 100 percent accuracy on encounters that were often incorrect in the past. We will soon turn the feature on more globally. One reason I think it has been so well received by the pilot group is that they are prompted to enter the diagnosis correctly at the point of service. They don’t have to come back to the chart later. Our goal is to make the right thing to do—the easy thing to do.

Leslie: It’s amazing that there wasn’t a need for more training.

Dr. Taylor: We made the system intuitive; however, for some alerts like the “cancer vs. history of,” we did do a little more in the way of training. For some alerts we sent a “job aid,” which is a pamphlet or flyer that includes screen shots of the instructions that will pop up, and some suggestions on how to respond. For one provider group, I met face to face for 15 minutes to explain the alert for “cancer vs. history of.” We also posted the definition and more complete criteria on our coding Web site, which is accessible through a hyperlink in the EHR

Leslie: How do the alerts work to support the physicians’ work flow processes?

Dr. Taylor: When physicians enter a diagnosis, the pop-up alert appears with a reminder. They can use the information as needed or choose to just close the box. They can also choose to click on a hyperlink that takes them to a criteria set that requires action. For example, the criteria set might have orders that they can select right then and there, or if not indicated for their patient, they can just close out the box.

Patty: Did the best practice alerts come with the system?

Dr. Taylor: The system came with alerts and reminders for health maintenance concerns like mammograms or pap smears. We added the diagnosis alerts. For example, if a chronic condition on the record isn’t addressed within a certain time period, such as diabetes, an alert will pop up at the next visit reminding the doctor to follow up and document the status of the patient’s condition related to that diagnosis.

If a patient’s history suggests he should have a certain procedure periodically, for example a colonoscopy every 3 years, the system can print a letter to send to the patient. Also, we customized some of the procedures for alerts that pop up to assure proper coding and documentation on those procedures. So, we did customize the system.

Kathy: It sounds like your best practice alerts improve care. Have you measured that?

Dr. Taylor: For one thing, we can now evaluate the impact of clinical education sessions. For example, we had education sessions for the hospitalists about malnutrition in patients coming from nursing homes. We did data pulls in the months following the educational sessions and saw a spike in the diagnosis and treatment of patients for this problem. This is important feedback for our medical education and quality assurance programs.

We also have built more sophisticated tools into the system to assure better care. One example is for patients with kidney disease. We built a calculator into the system that scans the record for the latest lab results, height, weight, age, body surface area, etc. and then computes the disease stage. If the calculator can’t find critical information, the physician is directed to the appropriate care plan. The outcome is better care for the patient and more complete and accurate documentation of the patient’s disease stage. Now the nephrologists can pull reports to study each disease stage. The EHR is helping doctors prevent further kidney disease in their patients.

Leslie: It sounds like you are achieving a lot more with your EHR than just improved documentation and coding. Do you think there is a clear connection between better patient care and financial outcomes?

Dr. Taylor: Absolutely. The improvements we are realizing drive better clinical outcomes, as well as more accurate Medicare reimbursement and more appropriate allocation of our resources.

Patty: You mentioned that the best practice alerts drive better clinical outcomes, support quality reviews and that they enable better documentation and coding. Do you see any conflict in the relationship between the practice guidelines and documentation for coding and reimbursement?

Dr. Taylor: We have been very cautious about avoiding even the appearance of conflict. Another doctor trains our physicians in procedure and level of service coding. She never translates the impact of the codes selected to the amount of money reimbursed.

I work with the physicians on accuracy and specificity of diagnoses. I stress the importance of coding all diagnoses and conditions, always reminding them to document what you do, and code what you document. In my role as the medical director of revenue cycle, I am also involved at times with evaluating RVU (relative value unit) trends and productivity. The medical director of coding education is never involved in these discussions.

Kathy: It is my understanding that you do regular coding accuracy audits for each provider.

Dr. Taylor: Yes, we do. We have improved the overall accuracy of evaluation and management (E/M) coding to 92 percent
and some groups are more than 95 percent. Each provider has
10 charts a month audited. If they maintain a 95 percent accuracy rate for 3 months they are considered billing certified, and their records are only reviewed quarterly. They stay billing certified unless a quarterly audit shows a drop to less than 95 percent, in which case that provider would be back to having a monthly audit and feedback session.

Leslie: Can you tell us more about the embedding of coding tools in your EHR?

Dr. Taylor: For level of service, the EHR vendor supplied a coding calculator that allowed for four levels of history, four levels of exam and four levels of medical decision making. It calculates the code, but didn’t give us definitions of problem focused, expanded problem focus, comprehensive, etc. so we built coding rules into the calculator. When the physician hovers the cursor over the button representing the level of history or exam, all options are listed and he can see if he did all of the items listed. If not, he can go down a level and hover to see if he did everything at that level, and so on. When he gets to the correct level, for example, low complexity, he clicks on that and the code is automatically assigned. It makes it really easy for the physician; he just needs to follow the instructions in the pop-up boxes.

Leslie: Are these codes also part of your auditing program?

Dr. Taylor: Yes. We do a 100 percent review for government billing programs. The HMO claims are included in the auditing program I described earlier.

Kathy: What is most unique about your approach?

Dr. Taylor: We changed the language of the pop-ups in the system from “code book speak” to “clinician speak.” For example, the code books refer to parental infusion of a controlled substance. We changed that to IV Narcotic. We simplified the language, which has been a huge hit with the doctors. Without addressing the issue of language, it was a big blur of words for the physicians. We put the most commonly occurring clinical scenarios in bold letters.

We also use pick lists of diagnoses, sequenced for the top diagnoses that each doctor treats based on their department. We provide all the options, but the preference list for each physician comes up first. If he doesn’t see the specific diagnosis that he wants, then he can hit a key that brings up a more comprehensive facility list. The physicians actually determine their own preference lists.

Patty: With all these great features embedded in the system, how has the role of the HIM professionals changed?

Dr. Taylor: There are two roles for HIM professionals that are particularly important to us: production or work queue coders, as we call them, and coding educators. We need the production coders because our doctors do not assign modifiers, and we need skilled coders to code or review any claim that would fail a claims scrubber edit, such as a claim that might become accidentally unbundled. However, we also need the coding educators. These are expert coders who do the billing certification audits. Each coding educator reviews 40 to 50 physicians’ records and provides feedback. This activity requires a higher level of coding skills as well as good interpersonal skills. They have to interact with the physicians, providing feedback, going to department meetings, doing data analysis, updates, etc.

Kathy: The EHR in your organization has become a great collaboration tool, which helps physicians and coders work together to achieve more accurate coding and documentation.

Dr. Taylor: Yes, and I always tell people that EHRs expand and elevate the roles of coders, especially in our organization, where we are going for a higher standard of accuracy and we are hyper-vigilant in monitoring physicians’ documentation and coding practices.

Leslie: Dr. Taylor, thank you for sharing your experience and insights, and for giving our readers a glimpse of a very exciting and challenging future. We look forward to visiting with you again.

Leslie Ann Fox is chief executive officer and Patty T. Sheridan is president, Care Communications Inc., Chicago. They invite readers to send their thoughts and opinions on this column to [email protected] or [email protected].