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HIM & Heard

CDI for Physicians Ready to Quit
December 19, 2012 8:02 AM by Stephanie Cecchini

Fast Facts:

The average medical school graduate is in $161,000 debt.

The now unchallenged Obama-care model creates a 63,000 physician shortage by 2015.

Forty-six percent of physicians would NOT choose medicine again as a career.

As we move into these unprecedented times in health care, our physicians need our support more than ever. It's hard to "buy in" when you are miserable - and without a physician's buy-in, education is a very difficult objective to meet. It requires much more than subject matter expertise ... it requires truly effective communication.

How can we communicate effectively with physicians who are overwhelmed and disenchanted? A physician will be more likely to listen and respond when you are able to communicate by both your actions and words an understanding of their needs, wants, and mindset. Typically life-long learners, physicians are highly intelligent, with a deep appreciation for logic and reason. They are naturally intuitive, some even feeling spiritually drawn to practice the art of medicine and healing. Generally hungry for and appreciative of tips and techniques in learning new skills, physicians crave correctness. Accurately documenting for coding and billing purposes can prove a frustrating dichotomy; it is both a challenge to achieve correctness, while also an intrusion that takes away from patient time.

As documentation coaches, there are steps we can take to help lighten the load on physicians
  • Address the physician's concerns openly, directly and with respect.
  • Accept that many physicians will view your documentation requirement education attempts as a low priority in lieu of the top priority: putting the patient first.
  • Learn how to overcome objections like a pro: Attend train-the-trainer programs and sales classes; in order to be successful you must first sell the CDI process to the physician.
  • Know the physician's personality type before you meet with him/her. The best face-to-face coaching time may be shadowing the physician on the hospital floor with short, immediate feedback or at a quiet time at his/her desk.
  • Be willing to rearrange delivery of the information in order to answer questions.

A physician may be frustrated; a good coach recognizes that these emotions are not personal. CDI "train-the-trainer" programs can be a critical tool to shore up your internal subject matter expertise with effective training techniques.
Living With the Black and White Problems of Grey Codes
August 10, 2012 8:11 AM by Stephanie Cecchini

In recent years, the government and private payers have taken a firm position on fraud and abuse. The Patient Protection and Affordable Care Act allows the Centers for Medicare & Medicaid Services to suspend payments when there are "credible allegations of fraud." It's increasingly important to avoid even the appearance of wrongdoing.

Adding fuel to the fire, in an election year, all eyes are on wasted tax dollars and high costs in health care.  Inaccuracies in the coding of physician visits are estimated to account for up to 3 percent of the medical loss ratio in commercial plans and up to 1 percent in Medicaid plans. Abuses, honest mistakes in billing for physician visits, account for estimated national losses in billions each year.

How can this be true when the vast majorities of physicians are committed to billing accurately and are legitimately surprised when mistakes are uncovered?

Evaluation and Management codes, the codes that bill for office visits, are subjective in nature. From the aspect of medical necessity, the correct level of service is determined simply by how sick a patient is. Conditions that pose an immediate threat to life or limb qualify for the highest code level, whereas patients with minor or well controlled problems are at the lowest; however, peers may see the same patient and assuming the same diagnosis may still argue how sick the patient really is.

Beyond medical necessity aspects, the rules that govern documentation requirements are also in many ways subjective. Reproducible audit results between unrelated documentation requirement auditors are not unfailingly prevailing. Properly trained and certified auditors may agree on the actual code selection better than 90 percent of the time; however the means and measurements of their conclusion can be different upwards of 50 percent.

This is partly due to the choice of two distinct guidelines used to measure the correct level of service. CMS'  "1995 Documentation Guidelines for Evaluation and Management Services" or "1997 Documentation Guidelines for Evaluation and Management Services" are the criteria used to determine whether documentation supports the level of service billed. CMS has instructed all Medicare carriers to use whichever one is more favorable for the physician. This means, on a claim by claim basis, the Evaluation and Management results are based on one of two sets guidelines and the judgment of the coder. Of larger concern is the various interpretations of the guidelines, and the vague criteria within them.

Complicating things further, a qualified coder may review a document and establish that a comprehensive service was rendered; however, a medical review may find the same document lacking in necessity. A comprehensive service may be a physician's personal art and style of practice but may not be considered necessary and billable by a majority of his or her peers. For example, a comprehensive history and physical may not be necessary to repeat on a two week follow-up visit to check the patient's normal blood pressure.

The worst thing a physician can do is to wait until the 11th hour of an audit to determine an audit response game plan. Just because someone disagrees with your code selection does not mean they are right. Evaluation and Management codes are notoriously subjective and overpayment requests may be overturned in an appeal with the right response to the initial audit results. Physicians who are unemotional about their coding are often times on stronger ground with solid and objective reasons for their coding. As a proactive measure, having an advance familiarity with clinical examples from creditable sources and specialty associations can be helpful. These are powerful because they establish objective measures where there is room for subjectivity. The most credible medical coding review comes from an unbiased peer and an established compliance expert.

Typically, the most effective way to ensure correct coding is with the help of an Evaluation and Management compliance expert. A few minutes of coding and documentation requirements education can prevent big problems from overpayments and losses from inaccurate coding.

Finding Opportunity in ICD-10 No Man’s Land
March 26, 2012 12:24 PM by Stephanie Cecchini

When it comes to the ICD-10 implementation deadline delay, there's no shortage of impassioned debate over the merits of staying the course in preparation, or using cash on hand for definite causes. What if you didn't have to pick sides? Clinical documentation assessments and improvement efforts can benefit you now, whether the ICD-10 change happens (quickly) or not.

Forget what you plan to do, what are you doing now? Are you under-documenting the patient's condition? RAC audits continue to find inappropriate payments. According to CMS, the Medicare Recovery Audit program has collected $1.27 billion in overpayments since October 2009. Does this mean that all of those services were not medically necessary? Were they all coding errors? Or ... was it a mix with simple under-documentation?

Whether or not you are a proponent of ICD-10, this delay in implementation allows for a valuable opportunity - a windfall in the void of a definitive deadline to establish your documentation weaknesses, shore them up, and code and bill properly in today's world of ICD-9 and be ready for whatever the future brings.


Health Care Business at the Drop of a Hat
February 15, 2012 3:29 PM by Stephanie Cecchini

It’s hard to look your best when you are wearing too many hats.  While the business of health care struggles in a depressed economy and a revenue cycle containing a growing number of under and uninsured, pending government regulations such as HITECH, the Affordable Care Act, HIPAA 5010 and ICD-10 conversions have produced, for many,  a nail-biting backdrop against patient care.  How does a health care provider achieve balance in these unprecedented times of change?


Further muddying strategic health care business planning is the opposing opinions from trusted health care associations.  While the American Medical Association (AMA), the largest association of physicians, calls on congress to stop the implementation of ICD-10, and the Medical Group Management Association (MGMA) asks the Centers of Medicare and Medicaid Services (CMS) to delay 5010 implementation, the American Health Information Management Association (AHIMA) declares that varying from prior rule making is a mistake that could ultimately increase costs.  With CMS’s agreement this week to “re-examine the time frame” for the ICD-10 transition, providers truly juggle mixed messages. Today's business of health care now seems to require outside assistance in order to manage all of the moving targets.  Where do providers find trusted partners? 


While many larger hospitals are quickly investing in the advice of big consulting firms, boutique consultancy firms should not be overlooked when seeking outsourced training and business support.  Aside from budget constraints, providers should analyze their culture to select the right partner.  While larger firms may offer greater choices, their support network may not be as personalized or easily accessible.  The best partners are thought leaders capable of effective planning and producing quality deliverables.  Providers who select their consulting partners based on their evaluation of the firm’s reputation, experience, and service philosophy will often have the best results. References should be asked for and checked.


Effective outsourcing can help providers navigate complex government regulations while protecting positive cash flow.  Wearing too many hats adds an unnecessary burden to providers who shouldn’t have to do it all.  Getting rid of a few lets most providers finish strong and focus on what matters most… their patients.  


ICD-9 sky is NOT falling?
February 8, 2012 10:38 AM by Stephanie Cecchini

Physicians have been told the ICD-9 sky is falling and their practice will grind to a halt if they don't properly prepare for ICD-10.  For over a decade the physician's practice has been fighting tangible tigers ---stiff regulatory compliance, decreased fee schedules, and increasing expenses. The result is that it became easy to tune out the ICD-10 chatter. The reality of an October 1, 2013 deadline means the time for action has arrived.  Although the impact of ICD-10 on physicians remains ambiguous for many, the bottom line is clear: there is a danger of revenue cycle performance issues, decreased productivity, and time lost from patient care.  What does the physician practice need to do to minimize the effect of uncertainty on objectives?

Educated staff and tailored documentation training for physicians are the most important steps a practice can take now to reduce revenue cycle and productivity risks.  While most physicians don't need to be as fluent in ICD-10 as a coder, they need to provide enough detail in their documentation for the coder to select a code with finer granularity.  This means efficiently tailoring the training to match the physician's unique style of practice.  The physician's medical specialty plays a big part in narrowing the learning curve.  For example, an orthopedic surgeon won't usually need to learn documentation requirements for trimester notations in OB care; nor do many cardiologists have interest in learning the requirements for documenting open fractures according to Gustilo classification.   Practices should begin with a review of their superbill to make a comparative study using CMS General Equivalence Mappings (GEMS) to crosswalk the old and new codes.  GEMS aren't a substitute for learning how to use the ICD-10-CM, which will take most coders an average of 15 to 25 hours.  It will help identify where to focus training for maximum efficiency.  Trained staff becomes the fastest and easiest resource for the physician.

Clinical Document Improvement (CDI) programs help to identify gaps and opportunities.  Practices that haven't yet started will lose an important advantage.  Preparing now spreads the necessary work and training across nearly two years, rather than facing it all at one time and sacrificing focus from patient care.  The ICD-9 sky is not falling yet, but waiting much longer to start CDI is risky.  The time to start is now.