THE ON-DECK CIRCLE Brandon Lewis, DO, MBA, FACOEP, FACEP

THE ON-DECK CIRCLE Brandon Lewis, DO, MBA, FACOEP, FACEP

A GENERATIONAL CHANGE

THE CENTERS FOR MEDICARE AND MEDICAID SERVICES HAVE INTRODUCED MASSIVE CHANGES IN HOW WE WILL GET PAID FOR THE WORK THAT WE DO.”

As we approach the new year, emergency physicians across the country can look forward to huge changes in how we work on a daily basis. The centers for Medicare and Medicaid services have introduced massive changes in how we will get paid for the work that we do. This has huge potential impacts on our practices and the healthcare system across the board.

All emergency physicians know that when billing a patient for your care, the level of services is determined by how you have documented the encounter. For example, the number of history elements that are included in your history of present illness (HPI) can determine whether you get paid for a low-level visit or high-level visit. Similarly, for a higher level visit a comprehensive review of systems and a detailed physical exam is required. Unless you meet a set number of systems reviewed and physical exam body parts described, you cannot recognize the true level of service that you have provided, regardless of how sick the patient is.

The results of this is that we as physicians end up having to spend extra time documenting a chart that may include things that are not relevant to the patient’s current medical condition. If not done properly it often results in under coding for the true level of service that you have provided. As a patch many practicing emergency physicians develop macros or templates that they used to document, or have hired a scribe to add most of this documentation for them.

The end result is that many charts often times are full of “click box “entries that do little to tell the story of the patient’s true condition or what transpired during the visit. Medical decision-making entries in the chart are usually fairly brief and also not as descriptive or useful as they should be.

Starting January 1, this all changes. While there is certainly the potential for some negative effects associated with this change, the new CMS documentation changes will focus more on the medical decision making that actually occurs during the visit and less on data entry.

Level of service will now depend on three factors: 1. the number and complexity of problems addressed, 2. the amount or complexity of data to be reviewed and analyzed, and 3. the risks of complications and/or morbidity and mortality to the patient you are seeing. Most of these things are all captured in your medical decision-making portion of the chart. The amount of history, review of systems and examination documented will play no role in how the level of service is determined. As usual, there are some specific terms and items that coders will be looking for to determine how complex the case was and how much risk is involved. I highly recommend that you talk to your coding team about what they are looking for in these areas.

In theory, a history and physical exam are not even required for coding purposes. Of course, we all know that a chart is more than just a coding document. More importantly the chart functions as a peer-topeer communication of the patient’s condition and treatments that were offered. Also the chart serves as a record of the patient’s condition and your thought process to defend you in the event of medical malpractice assertions. These things of course do necessitate a reasonable history and physical exam, so we cannot throw the entire baby out with the bath water so to speak.

While one may call me a “glass is half-full” kind of guy, I think there are some positives that come from these changes. Going forward the time that I spent documenting a patient encounter will focus much more on truly “telling the story” of the encounter and far less time will be spent and checking boxes to meet arbitrary coding requirements for history and physical exam elements. The only person that may suffer from this is my scribe as the utility of scribes may be a far less value going forward! Good luck with these changes and let us know if there is anything ACOEP can do to help you adapt to the new world of documentation! –•–

I HIGHLY RECOMMEND THAT YOU TALK TO YOUR CODING TEAM ABOUT WHAT THEY ARE LOOKING FOR IN THESE AREAS.”