Providers, Now is the Time to Change How we Document!

By Andrew B. Maigur, MD, system director, Premier Physician Advisor Program, Premier Health

While most of us rang in the New Year, either with friends and family or caring for our patients at the bedside, something changed in the regulatory world of health care with a considerable impact on provider revenue. As of January 1, 2023, the Centers for Medicare and Medicaid Services (CMS) and Outpatient Prospective Payment System (OPPS) 2023 Final Rule went into effect. To reduce the administrative burden on providers, CMS revised the Evaluation & Management (E&M) coding guidelines for inpatient providers.

Substantial changes were made, including eliminating E&M observation codes and combining inpatient and observation hospital E&M services into a single existing E&M code set. Understandably, this created a great deal of confusion, with providers assuming that observation status had been abolished. I want to clarify that observation status has not been eliminated. The two-midnight rule is still in effect for Medicare patients, and commercial payers will continue to use commercial criteria to determine admission status.

A tremendous change for the inpatient E&M code set is the elimination of required elements for the History of Presenting Illness (HPI) Review of Systems (ROS), family history, social history, physical exam, and the bulk of the weight now falls on Medical Decision- Making (MDM). Now more than ever, medical necessity documentation will play a vital role. Clearly spelling out the reason for hospitalization, enumerating potential medical risk to the patient if the condition were not treated in the hospital, and supporting daily hospitalization with a medical need adds to the complexity of MDM.

Clinical Documentation Integrity (CDI) positively impacts MDM, e.g., symptoms like "altered mental status" versus a diagnosis of "Acute Metabolic Encephalopathy" influences the complexity and severity. Document using descriptive words such as acute and chronic, rather than “history off,” severe, moderate, etc. Link diagnosis to possible etiologies, document treatment options, comorbidities that affect treatment and their clinical impact on patient outcomes. Avoid using generic words like "stable," which is subjective; instead, use "improving but not at baseline," which indicates the need for continued care in the hospital. Collaborate with the CDI and coding teams to enhance your documentation. CDI coding queries are not meant to question your clinical judgment but rather to improve the specificity of your documentation, which in return impacts your E&M coding.

Now is also the time to address the copy-and-paste and copy forward functionality in the EMR Electronic Medical Record (EMR). While we all agree copy and paste is an efficient, time-saving tool, when not used compliantly it can lead to inaccuracies, misrepresentation, and potential regulatory and medical-legal challenges. CMS concurs "healthcare professionals have stated that copying and pasting notes can be appropriate and eliminate the need to create every part of a note and reinterview patients about their medical history. However, The US Department of Health and Human Services Office of Inspector General (HHS–OIG) identifies illegitimate use of cut and paste record cloning as a problem."  In the new E&M guidelines, copying and pasting material when not updated or edited to accurately reflect the care provided during the encounter would not necessarily count toward medical decision-making. Also, copying and pasting test results without any analysis demonstrating clinical significance does not contribute to the level of data to review and analyze. Rather than copying forward a physical exam, document a new, medically necessary exam with pertinent findings for each patient encounter.

These guideline changes further bolster efforts to curb note bloat. Links that pull in historical labs, imaging test results, and procedure notes do not contribute towards MDM. Simply declaring the specific test results, medical records reviewed, and the clinical significance of the current episode of care would be sufficient. Several health systems have leveraged technology within the EMR and created specialty specific standardized note templates.  Using the functionality of hyperlinks, the provider can access distinct parts of the EMR from their note without pulling in extraneous data into the note while keeping their note open. The ability to create disappearing tips with rule-based decision support serves as real-time reminders to address documentation deficiencies that impact quality metrics and reduce the number of coding and CDI Queries, thus limiting workflow interruptions.

The medical record serves as a communication and handoff tool between providers and other care team members. It is also accessible to our patients, health-insurance payers, auditors, attorneys, etc. Now more than ever, we as a provider community have an opportunity to craft concise, accurate, clinically relevant, high-quality documentation with minor tweaks to our existing documentation practices and note templates.

Back to the January 2023 issue of Premier Pulse