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COURSE 320 DOCUMENTATION
WITH TRAINEES AND LEVERAGING
THE EHR
Mark Huang, M.D.
Chief Medical Information Officer
Rehabilitation Institute of Chicago
Associate Professor
Department of PM & R
Feinberg School of Medicine
Northwestern University
DISCLOSURES
No personal disclosures
The Rehabilitation Institute of Chicago collaborates with Cerner Corporation in the development of rehabilitation content
OBJECTIVES
Discuss documentation requirements when working with trainee
Analyze examples of leveraging the EHR– Documentation– Orders
Discuss implications of meeting meaningful with assistance of the trainee
CMS GUIDELINES
Clear identification that you are the teaching physician
Bill with GC modifier When you bill E/M services, you must
personally document at least the following: – You performed the service or were physically
present during the critical or key portions of the service furnished by the resident
– Your participation in the management of the patient.
CMS manual system pub 100-04 transmittal 2303
REIMBURSEMENT
Evaluation and management codes – level of service is combination of what resident
documents as well as attending
Procedure codes– based on combined services of resident and TP
Modifiers:– Attach GC modifier
SCENARIO 1
Teaching physician personally performs all required elements for E/M service (office visit)– Resident may or may not have performed E/M
services– TP note references resident note– Must document performed the critical or key
portion(s) of the service, and that he/she was directly involved in the management of the patient
– If NO resident note, TP must perform all required documentation
SCENARIO 2
The resident performs office visit in the presence of, or jointly with teaching physician; resident documents the service. – TP documents that he/she was present during the
performance of the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient.
– TP note should reference the resident’s note.
SCENARIO 3
The resident performs some or all required elements of the service separately from TP and documents his/her service. TP independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. – TP documents that he/she personally saw patient,
personally performed key portions of service, and participated in the management of the patient.
– The TP note references the resident’s note.
SCENARIO 4 (MAINLY INPATIENT)
Resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day: – TP documents that he/she personally saw the
patient and participated in the management of the patient.
– TP may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note.
SCENARIO 4
– TP note must reflect changes in the patient's condition and course at the time the patient is seen by the TP.
– The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making
PROCEDURES
Procedures– You must be present for key portions of the
procedure– If procedure is brief (less than 5 minutes) you must
be present for entire procedure to bill for service– Resident can document procedure but should state
who was supervising physician– While not specifically stated, best for attending to
co-sign note and state their presence during procedure
MEDICAL STUDENTS
Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements.
You may only refer to the student’s documentation of the ROS and/or PFSH.
For the HPI, exam, and decision making you must personally document these elements
MEDICAL STUDENT DOCUMENTATION
You must verify and re-document the history of present illness, and perform and re-document the physical examination and medical decision making activities of the service.
ACCEPTABLE PHRASES
“I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
“I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
ACCEPTABLE PHRASES
“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
“I saw the patient with the resident and agree with the resident’s findings and plan.”
ACCEPTABLE PHRASES
I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with lumbar stenosis. Will begin PT.”
“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
“I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”
NOT ACCEPTABLE
Agree with above Rounded, reviewed, agree Discussed with resident, agree Patient seen and evaluated Signature alone
LEVERAGE EHR WITH RESIDENT
Use of note templates Automated TP linking statements
– Create autotext phrases– Use of macros
Order sets
MEDICARE AND THE EHR
“You may use a macro, a command in a computer or dictation application in an electronic medical record that automatically generates predetermined text that is not edited by the user, as the required personal documentation if you personally add it in a secured or password-protected system.”
In addition to your macro, either you or the resident must provide customized information that is sufficient to support a medical necessity determination.
MEDICARE AND THE EHR
The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date.
If both you and the resident use only macros, this is considered insufficient documentation.
USE OF TEMPLATES
Create templates for common complaints Generic template for patients that “just don’t fit
a template” Use them as education tools for residents as to
common areas to assess and address
TEMPLATES: HPI
TEMPLATES: EXAM
TEMPLATES: PLAN
DOCUMENTATION IN EHR
Create separate note referring to resident note Addend or modify resident note
– Best to make clear what is your documentation
TEACHING PHYSICIAN ATTESTATIONS
EXAMPLES OF AUTOTEXT
OUTPATIENT INPATIENT
COMBINED NOTES
OUTPATIENT INPATIENT
PROCEDURE NOTES
DOCUMENTATION TRAINING POINTS
Train residents in learning to appropriate update each note to reflect the current visit
“Copy and paste” wisely– Identify original source if they were not original
author
Make it clear in documentation what was done on today’s visit– BOLD or ITALICS– New paragraph with date
PERILS OF CUT AND PASTE
A real issue of concern Increased scrutiny from CMS and private
insurers– Denial of payment, concerns of fraud
2003 study in VA– 50% notes contain cut and paste– 10% felt to be high risk: “Human, clinically
misleading, major risk”
Hammond, KW, AMIA Symposium Proceedings 2003
EXAMPLES OF BAD CUT AND PASTE
Hammond, KW, AMIA Symposium Proceedings 2003
APPROPRIATE CUT AND PASTE
VOICE RECOGNITION
Voice recognition well suited for attending attestations
Dragon dictation– Dictate your TP addendums right away, add to
resident note when completed
Create voice recognition “macros” or autotext” Caveats:
– Watch accuracy– Word subsititution
ORDERS
Create order sets for common outpatient scenarios
Provides resident once place to find common orders
Helpful to establish standards of care
ORDER SET EXAMPLES
THERAPY ORDER SET BONE HEALTH ORDER SET
MEANINGFUL USE PAIN POINTS
Medication reconciliation Visit summary Patient education Eprescribe Electronic physician documentation Transition of care documents
MEANINGFUL USE
Educate residents in requirements (they need to know anyway!)
Put resident in charge of completion of these tasks– OK for resident to prescribe, make sure they are
configured in your system to do so
TIPS TO SUCCESS
Split tasks– Resident does certain MU components– Starts documentation or orders in room while you
are talking with patient– You can complete visit summary while resident
starts on next patient– See patients concurrently
TIPS TO SUCCESS
Appropriate set-up– Adequate number of exam rooms
Spend a few minutes teaching them the templates– When to use– When to “freetext”– Computer/chart access
The more you prepare the resident, the better the note quality= the less you need to document!
TAKEAWAYS
Understand documentation requirements for teaching physicians
Use the EHR to promote efficiency Residents can assist in completion of
regulatory requirements such as meaningful use