Practice Management

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.

SHM’s coding education program, CODE-H, now has an interactive component through the SHM Learning Portal. CODE-H originally was developed as a series of live and on-demand webinars complemented by online forums; today, CODE-H Interactive brings the same expertise to an interactive platform ideal for new hospitalists learning the nuances of coding, hospital medicine groups assessing the coding skills of their caregivers, or even coders using it as a training tool for conducting audits of hospital medicine groups.

To learn more about CODE-H and CODE-H Interactive, visit www.hospitalmedicine.org/codeh.

In February, SHM published the first performance assessment tool for HM groups. Now, HMGs across the country are using the “Key Principles and Characteristics of an Effective Hospital Medicine Group” to better understand their organizations’ strengths and areas needing improvement. Knoxville-based TeamHealth is the first to share its findings with SHM and The Hospitalist.

click for large version

Before SHM published the assessment tool, there were very few objective attempts to provide guidelines that define an effective HMG. At TeamHealth, we viewed this tool as a way to proactively analyze our HMGs—a starting point if you will, to measure our performance against the principles identified in this assessment.

To this end, we allocated an internal analyst to work with our regional leadership teams. We felt it was important to have one person coordinating the analysis in order to ensure consistency with regard to how performance was defined. The analyst, along with the regional medical director and vice president of client services, went through each of the 47 key characteristics and identified the program’s status by evaluating the following statements:

• This characteristic does not apply to our HMG;
• Yes, we fully address the characteristic;
• Yes, we partially address the characteristic; or
• No, we do not materially address the characteristic.

For purposes of scoring, we then assigned a weight to each of the characteristics: three points if “fully addressed”; two points if “partially addressed”; one point if not addressed. We did not find that any of the characteristics fell under the “does not apply to our HMG” category.

A “100% effective” HMG was defined as scoring the highest possible score of 141 (i.e., three points for “fully addressing” each of the 47 characteristics).

We are currently at the next step in our assessment process. This step involves completion of a scorecard for each individual HMG (see Table 1). Additionally, the individual HMG score will be benchmarked against TeamHealth Hospital Medicine performance overall.

Finally, our regional teams will take the scorecard and meet with their hospital administrators to review the assessment tool, our methodology for completion, and the hospital’s performance.

We fully recognize that some of our hospital partners have measurement standards that differ from those presented by SHM in this assessment; nonetheless, TeamHealth feels the tool in its present state is a significant first step toward quantifying a high-functioning HMG—and will ultimately help improve both hospitalists and hospital performance.

Roberta P. Himebaugh is executive vice president of TeamHealth Hospital Medicine.

In February, SHM published the first performance assessment tool for HM groups. Now, HMGs across the country are using the “Key Principles and Characteristics of an Effective Hospital Medicine Group” to better understand their organizations’ strengths and areas needing improvement. Knoxville-based TeamHealth is the first to share its findings with SHM and The Hospitalist.

click for large version

Before SHM published the assessment tool, there were very few objective attempts to provide guidelines that define an effective HMG. At TeamHealth, we viewed this tool as a way to proactively analyze our HMGs—a starting point if you will, to measure our performance against the principles identified in this assessment.

To this end, we allocated an internal analyst to work with our regional leadership teams. We felt it was important to have one person coordinating the analysis in order to ensure consistency with regard to how performance was defined. The analyst, along with the regional medical director and vice president of client services, went through each of the 47 key characteristics and identified the program’s status by evaluating the following statements:

• This characteristic does not apply to our HMG;
• Yes, we fully address the characteristic;
• Yes, we partially address the characteristic; or
• No, we do not materially address the characteristic.

For purposes of scoring, we then assigned a weight to each of the characteristics: three points if “fully addressed”; two points if “partially addressed”; one point if not addressed. We did not find that any of the characteristics fell under the “does not apply to our HMG” category.

A “100% effective” HMG was defined as scoring the highest possible score of 141 (i.e., three points for “fully addressing” each of the 47 characteristics).

We are currently at the next step in our assessment process. This step involves completion of a scorecard for each individual HMG (see Table 1). Additionally, the individual HMG score will be benchmarked against TeamHealth Hospital Medicine performance overall.

Finally, our regional teams will take the scorecard and meet with their hospital administrators to review the assessment tool, our methodology for completion, and the hospital’s performance.

We fully recognize that some of our hospital partners have measurement standards that differ from those presented by SHM in this assessment; nonetheless, TeamHealth feels the tool in its present state is a significant first step toward quantifying a high-functioning HMG—and will ultimately help improve both hospitalists and hospital performance.

Roberta P. Himebaugh is executive vice president of TeamHealth Hospital Medicine.

In February, SHM published the first performance assessment tool for HM groups. Now, HMGs across the country are using the “Key Principles and Characteristics of an Effective Hospital Medicine Group” to better understand their organizations’ strengths and areas needing improvement. Knoxville-based TeamHealth is the first to share its findings with SHM and The Hospitalist.

click for large version

Before SHM published the assessment tool, there were very few objective attempts to provide guidelines that define an effective HMG. At TeamHealth, we viewed this tool as a way to proactively analyze our HMGs—a starting point if you will, to measure our performance against the principles identified in this assessment.

To this end, we allocated an internal analyst to work with our regional leadership teams. We felt it was important to have one person coordinating the analysis in order to ensure consistency with regard to how performance was defined. The analyst, along with the regional medical director and vice president of client services, went through each of the 47 key characteristics and identified the program’s status by evaluating the following statements:

• This characteristic does not apply to our HMG;
• Yes, we fully address the characteristic;
• Yes, we partially address the characteristic; or
• No, we do not materially address the characteristic.

For purposes of scoring, we then assigned a weight to each of the characteristics: three points if “fully addressed”; two points if “partially addressed”; one point if not addressed. We did not find that any of the characteristics fell under the “does not apply to our HMG” category.

A “100% effective” HMG was defined as scoring the highest possible score of 141 (i.e., three points for “fully addressing” each of the 47 characteristics).

We are currently at the next step in our assessment process. This step involves completion of a scorecard for each individual HMG (see Table 1). Additionally, the individual HMG score will be benchmarked against TeamHealth Hospital Medicine performance overall.

Finally, our regional teams will take the scorecard and meet with their hospital administrators to review the assessment tool, our methodology for completion, and the hospital’s performance.

We fully recognize that some of our hospital partners have measurement standards that differ from those presented by SHM in this assessment; nonetheless, TeamHealth feels the tool in its present state is a significant first step toward quantifying a high-functioning HMG—and will ultimately help improve both hospitalists and hospital performance.

Roberta P. Himebaugh is executive vice president of TeamHealth Hospital Medicine.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

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Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

click for large version

Medical decision-making (MDM) mistakes are common. Here are the coding and documentation mistakes hospitalists make most often, along with some tips on how to avoid them.

Listing the problem without a plan. Healthcare professionals are able to infer the acuity and severity of a case without superfluous or redundant documentation, but auditors may not have this ability. Adequate documentation for every service date helps to convey patient complexity during a medical record review. Although the problem list may not change dramatically from day to day during a hospitalization, the auditor only reviews the service date in question, not the entire medical record.

Hospitalists should be sure to formulate a complete and accurate description of the patient’s condition with an analogous plan of care for each encounter. Listing problems without a corresponding plan of care does not corroborate physician management of that problem and could cause a downgrade of complexity. Listing problems with a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) equally diminishes the complexity and effort put forth by the physician.

Clearly document the plan. The care plan represents problems the physician personally manages, along with those that must also be considered when he or she formulates the management options, even if another physician is primarily managing the problem. For example, the hospitalist can monitor the patient’s diabetic management while the nephrologist oversees the chronic kidney disease (CKD). Since the CKD impacts the hospitalist’s diabetic care plan, the hospitalist may also receive credit for any CKD consideration if the documentation supports a hospitalist-related care plan, or comment about CKD that does not overlap or replicate the nephrologist’s plan. In other words, there must be some “value-added” input by the hospitalist.

Credit is given for the quantity of problems addressed as well as the quality. For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization. Established problems are less complex than new problems, for which a diagnosis, prognosis, or care plan has not been developed. Severity of the problem also influences complexity. A “worsening” problem is considered more complex than an “improving” problem, since the worsening problem likely requires revisions to the current care plan and, thus, more physician effort. Physician documentation should always:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• Note management options to be continued somewhere in the progress note for that encounter (e.g. medication list) when documentation indicates a continuation of current management options (e.g. “continue meds”).

Considering relevant data. “Data” is organized as pathology/laboratory testing, radiology, and medicine-based diagnostic testing that contributes to diagnosing or managing patient problems. Pertinent orders or results may appear in the medical record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note, or make an entry that refers to another auditor-accessible location for ordered tests and studies; however, this latter option jeopardizes a medical record review due to potential lack of awareness of the need to submit this extraneous information during a payer record request or appeal.
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”); credit is not given for entries lacking a comment on the findings (e.g. “CXR reviewed”).
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary; be sure to identify the increased efforts of reviewing the considerable number of old records by stating, “OSH (outside hospital) records reviewed and shows…” or “Records from previous hospitalization(s) reveal….”
• Indicate when images, tracings, or specimens are “personally reviewed,” or the auditor will assume the physician merely reviewed the written report; be sure to include a comment on the findings.
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

click for large version

Data credit may be more substantial during the initial investigative phase of the hospitalization, before diagnoses or treatment options have been confirmed. Routine monitoring of the stabilized patient may not yield as many “points.”

Undervaluing the patient’s complexity. A general lack of understanding of the MDM component of the documentation guidelines often results in physicians undervaluing their services. Some physicians may consider a case “low complexity” simply because of the frequency with which they encounter the case type. The speed with which the care plan is developed should have no bearing on how complex the patient’s condition really is. Hospitalists need to better identify the risk involved for the patient.

Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining to the presenting problem, diagnostic procedures ordered, and management options selected. The single highest-rated item detected on the Table of Risk determines the overall patient risk for an encounter.¹ Chronic conditions with exacerbations and invasive procedures offer more patient risk than acute, uncomplicated illnesses or noninvasive procedures. Stable or improving problems are considered “less risky” than progressing problems; conditions that pose a threat to life/bodily function outweigh undiagnosed problems where it is difficult to determine the patient’s prognosis; and medication risk varies with the administration (e.g. oral vs. parenteral), type, and potential for adverse effects. Medication risk for a particular drug is invariable whether the dosage is increased, decreased, or continued without change. Physicians should:

1. Provide status for all problems in the plan of care and identify them as stable, worsening, or progressing (mild or severe), when applicable; don’t assume that the auditor can infer this from the documentation details.
2. Document all diagnostic or therapeutic procedures considered.
3. Identify surgical risk factors involving co-morbid conditions that place the patient at greater risk than the average patient, when appropriate.
4. Associate the labs ordered to monitor for medication toxicity with the corresponding medication; don’t assume that the auditor knows which labs are used to check for toxicity.

Varying levels of complexity. Remember that decision-making is just one of three components in evaluation and management (E&M) services, along with history and exam. MDM is identical for both the 1995 and 1997 guidelines, rooted in the complexity of the patient’s problem(s) addressed during a given encounter.^1,2 Complexity is categorized as straightforward, low, moderate, or high, and directly correlates to the content of physician documentation.

Each visit level represents a particular level of complexity (see Table 1). Auditors only consider the care plan for a given service date when reviewing MDM. More specifically, the auditor reviews three areas of MDM for each encounter (see Table 2), and the physician receives credit for: a) the number of diagnoses and/or treatment options; b) the amount and/or complexity of data ordered/reviewed; c) the risk of complications/morbidity/mortality.

To determine MDM complexity, each MDM category is assigned a point level. Complexity correlates to the second-highest MDM category. For example, if the auditor assigns “multiple” diagnoses/treatment options, “minimal” data, and “high” risk, the physician attains moderate complexity decision-making (see Table 3).

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed July 7, 2014.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed July 7, 2014.
3. American Medical Association. Current Procedural Terminology: 2014 Professional Edition. Chicago: American Medical Association; 2013:14-21.
4. Novitas Solutions. Novitas Solutions documentation worksheet. Available at: www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966. Accessed July 7, 2014.

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Presenters

--- Welcome Remarks: Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs, St. Louis Children’s Hospital

--- The Next Phase of Delivery System Reform: Patrick Conway, MD, MSc, FAAP, MHM, deputy administrator for innovation and quality, CMO for the Centers for Medicare & Medicaid Services (CMS)

--- Hospitals and Health Systems: What’s on the Mind of Your CEO?: David J. Bailey, MD, MBA, president and CEO, the Nemours Foundation; Steve Narang, MD, MHCM, CEO, Banner Good Samaritan Medical Center, Phoenix, Ariz.; Jeff Sperring, MD, FAAP, president and CEO, Riley Hospital for Children at Indiana University Health, Indianapolis.

Summary

PHM 2014 began to heat up in steamy Orlando, as Dr. Carlson, chair of the PHM 2014 Organizing Committee, welcomed more than 800 pediatric hospitalists at the four-day annual meeting dedicated to pediatric hospital medicine.

Dr. Conway, a pediatric hospitalist prior to joining CMS, updated the crowd of ongoing reforms in the U.S. healthcare delivery system, with a focus on pediatrics. Healthcare delivery, Dr. Conway asserted, needs to move from an unsustainable, volume-driven, fee-for-service system to a people-centered, sustainable system where payment can be shaped by value-based purchasing, ACO-shared savings, and episode-based payments.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement, and population health.”

As such, the six goals of the CMS Quality Strategy align well with ongoing PHM efforts:

• Make care safer by reducing harm caused in care delivery;
•  Strengthen patient and family engagement as partners in their care;
•  Promote effective communication and coordination of care;
•  Promote effective prevention and treatment of chronic disease;
•  Work with communities to promote healthy living; and
•  Make care affordable.

Citing Maryland as an example, where a plan is being considered to shift 80% of hospital revenues to global models by 2018, Dr. Conway painted a picture of a rapidly-shifting reimbursement landscape that will soon be dominated by value-based purchasing, penalties for readmissions and healthcare-acquired conditions, and increasing emphasis on bundled payments, ACOs, and primary care medical homes.

“Hospitals are getting paid to keep people out of the hospital,” he said, and concurrently per capita spending on healthcare is now at historic lows. While pediatric quality measures are not as mature as those for adult patients, many opportunities for increasing value in pediatric care have been developed, such as the Choosing Wisely campaign and the Value in Inpatient Pediatrics (VIP) network.

Although not restricted to pediatrics, the CMS Partnership for Patients also aims to have a major impact on child health. Goals of a 40% reduction in HACs and 20% reduction in preventable 30-day readmissions have been set by the Partnership, with specific focus on 10 core patient-safety areas. Preliminary data have been promising, with a 9% reduction in HACs between 2010 and 2012 across all measures.

“This is a historical reduction,” said Dr. Conway, representing more than 500,000 patient harm events avoided, over 15,000 lives saved, and more than $4 billion in cost savings.

Within pediatrics, a number of research efforts have added to this reduction, including the Pediatric Research in Inpatient Settings (PRIS) Network, PHIS+, I-PASS, as well as several collaborative improvement networks.

Looking to the future, Medicaid and Children’s Health Insurance Program will continue to focus on quality initiatives and system transformation. These will include developing more pediatric-focused quality measures, improving health information technology, and continuing to award innovation in pediatrics. Pediatrics will continue to be a leader in these efforts, Dr. Conway said, because “we should care about longer time horizons.”

Four healthcare system CEOs also took the stage to answer questions from the audience, with Mark Shen, MD, president of Dell Children’s Medical Center, posing questions like a seasoned talk-show host. Panel members fielded a wide range of questions, including:

— How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

— What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds…It depends on ACO penetration whether quality or volume will be the driver over the next 3-5 years,” Dr. Narang said.

“We have to create an accountable health community,” Dr. Shen said.

“The question is, how can you build a model that will allow you to flip the switch when this change occurs?” Dr. Sperring said.

— What is the role of hospitalists as care progresses from the most intensive but sometimes least appropriate site?

“I think the environment will drastically change, but there will be an ever enlarging role for hospitalists. … Hospitalists will likely be moving to LTACs, SNFs, even outpatient work.” Dr. Bailey said.

— If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. … I don’t think we’re going to be at a point where certification will limit being a hospitalist any time soon,” Dr. Shen said.

— How can we make health care pricing more transparent?

“Why is it that in other industries, things are getting cheaper and higher quality, but in healthcare we seem to be going in the opposite direction?” Dr. Bailey said. “There has to be transparency for the patient. How about transparency for the provider? Every EMR should have a price for everything your order.”

— What do you think we can do to get more women into executive roles?

“Based on the percentages of women in medical school, residencies, and fellowships, I think it is inevitable that women will be the future leaders for our system,” Dr. Sperring said.

— What are the three most important things from a CEO perspective that a hospitalist should know?

“You have to have self-awareness…as a leader, are you a listener, are you a delegator?” Dr. Bailey said.

“Know where your organization wants to go,” Dr. Sperring said.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.