This transcript was exported on Apr 02, 2020 - view latest ......Page 2 of 29 that they're coding...

This transcript was exported on Apr 02, 2020 - view latest version here.

National Association of Community Health Centers (Completed 03/19/20)Transcript by Rev.com

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Elizabeth Zepko:

Hello and good afternoon to everyone. Good morning to folks out there on the West coast. Hello and welcome to today's webinar, Recommendations For Outlining Patient Risk, sponsored by the National Association of Community Health Centers. My name is Elizabeth Zepko. I'm a Program Associate in the Training and Technical Assistance Department here at NACHC, and I'm pleased to bring you this webinar along with my colleague Sherry Gimmer, Director of Healthcare Operations and Training. Before we get started, I would like to review a few housekeeping announcements. You have joined this online event by calling in. All lines have been automatically muted. This is to avoid any background noise interference. The duration of the is approximately two hours. This includes 90 minutes of introduction, presentation, and then we have a 30 minute Q &A at the end of the webinar.

Elizabeth Zepko:

At anytime during the webinar you would like to ask a question, please place this in the Q&A box located in the lower right hand side of your computer screen. Again everybody, if you wouldn't mind taking a moment and located in the Q&A box, it's located in the lower right hand side of your computer screen. Type your questions in and hit submit, and we will answer the questions in the time allotted. Throughout the webinar, we just wanted to make you guys aware, we will be answering periodically throughout the webinars some questions, but we'll be leaving the bulk of them towards the end of the webinar during that 30 minutes of Q&A.

Elizabeth Zepko:

Let us remind you that, again, today's event is being recorded and will be available on the MyNACHC Learning Center. You'll be also asked to complete three polling questions throughout the webinar, but I'll get to that once we get close on how to vote and how to submit your responses. After the webinar, you'll be presented with a brief survey. This survey lets us know how we did, how valuable this webinar was to you, and directly informs us of future training and technical assistance. We value your feedback and encourage you to complete this survey. At this time, I'm going to turn things over to Sherry. She'll be introducing today's speaker and setting the stage.

Sherry Gimmer:

Sherry. Thank you Liz. Welcome everyone. Good morning and good afternoon as Liz said. NACHC is pleased to offer this training, the Recommendations For Outlining Patient risk. I'd like to introduce our speaker today. Shellie Sulzberger is the co-founder and President of Coding and Compliance Initiatives in Kansas city. She has worked with NACHC for a number of years, and our conferences, providing technical assistance. She has over 20 years of experience in the healthcare industry, with experience as a nurse and internal compliance auditor, and a healthcare consultant. She has a unique background that she is able to relate to the coding side of it, billing side of it, and also to the clinician. So I think this webinar has a diverse audience, and I think your experiences will... I think questions, will benefit us. Please do ask questions when you have the time allotted, and I'll go ahead and turn it over to Shellie.

Shellie Sulzberger:

Good morning and good afternoon. So today we're going to talk about recommendations for outlining the patient risk. As you know, as we move more and more towards value-based health care and risk-adjusted healthcare, the dynamics are changing for all types of entities including FQHCs. So a little bit about my background, my connection to coding and documentation is, I am a certified professional coder. I work all over the country helping practices with coding and documentation reviews, to ensure

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that they're coding and billing correctly, and also that their documentation is credible not only for coding and billing but also for patient safety, legal liability, and just good patient care.

Shellie Sulzberger:

My connection to the clinical process is I am a nurse by background. I did work in an internal medicine clinic for many years with a provider. So I understand what happens in the room, is not always what is documented. And I understand the operational side on, especially as we are becoming more and more focused on quality, and there's more for the providers to do, how we really need to utilize our clinical staff to make more of a team effort. My connection to ICD-10 is I am a certified ICD-10 trainer, so I do help practices with coding to the highest level specificity, which again ties back to the coding and documentation review.

Shellie Sulzberger:

It's going to be very important as we move to this more value-based healthcare and MACRA and MIPS, to talk about how sick is that patient. And when your payers only receive a claim form, and not really knowing your patients, it's going to be very important tying that ICD-10 code on the claim form to the highest level of specificity. And then my connection to you is I do work with health care practices like yours all over the country, with coding and documentation, compliance, operations, et cetera.

Shellie Sulzberger:

So there's no legal advice in this. Again, this is really just my opinions and experiences over the years of working with practices. As we know, every Medicaid contractor has a little bit different rules. So what we're going to talk about today really won't impact any of that. It's really just documentation from the most credible and accurate regarding the work that's performed by the provider as well as the safety and the risk of that patient.

Shellie Sulzberger:

At the end of this two hour session, you should be able to compare the current model of how you're paid, moving to the more future model outlining, again, that risk adjustment for the patient. You'll be able to explain why clinical documentation is going to be critical from a compliance as well as a reimbursement standpoint, and also from the patient care perspective. We're going to identify the most common clinical documentation issues because we know as we move forward to ensure compliance and complete accurate and credible documentation, it's going to be very important that providers and staff understand how to reflect the severity of that patient's condition, the care that was delivered into the actual documentation, and then to relay that on a claim form.

Shellie Sulzberger:

So when we're thinking about risk adjustment, it's really not a new concept. Risk adjustment was a process by CMS, which is the Center for Medicare and Medicaid Services, really to predict health care costs based upon the risk of the enrolled patients into the health plan. And then Medicaid began using the risk adjustment model somewhere in the early '90s. And they were looking at this risk adjustment model since about 2004. So it's not really a new model, when we're thinking about risk adjustment and value-based. It's been in the process for quite a while.

Shellie Sulzberger:




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And, then we know as healthcare landscape continues to shift back and forth, coding and documentation is definitely increasingly driving reimbursement, but it's also driving quality measures as well as medical home models. So it's really teaching providers and clinical staff to understand the risk factor and the work that's done, and how do we get that documented as well as, how do we portray that on our claim form, so a payer really understand everything that that providers thinking about, and really, the overall risk of that patient. So risk adjustment is really just a form of a case mix index that they use as a predictive modeling tool. So actuaries are playing in that level of fields to figure out the patient outcome, and how to adjust the differences regarding the risk among that classified list of patients.

Shellie Sulzberger:

So we're going to have a poll question and what we're looking for is just to tell me the role in your health center, the CEO or upper management, CFO, operations officer, a provider. And this could be an MD, behavioral health PANP, et cetera, biller, coder or other.

Sherry Gimmer:

Awesome. Shellie. Thank you. And we're going to go ahead and keep that poll open for maybe 30 more seconds folks. So poll question is going to be in the lower right hand side of your computer screen. All you have to do is click your response and hit submit and we will get that information. We've got about five more responses that we're waiting for. Thank you to the folks that have already voted. We appreciate it. And I will go ahead and close this. And Shellie, you should be able to see the results now.

Shellie Sulzberger:

Yep, I can. Okay. It looks like 'other' is our biggest percentage, at 37%. Billing staff is about 20%. Coders is about 13%, 10% providers. And then a combination between our CEOs, CFOs, and COOs, somewhere around 7%. So let's talk about our current model, FQHC that are falling under Medicare, Medicaid, most of you are paid on your PPS rates. However, for your commercial payers, it's been a fee-for-service. So your reimbursement and compensation has really been based upon the level of service that you bill on your claim form. What we tend to find with FQHCs, is providers always tend to under-bill, based upon the risk of the patient, because they were always given a lump sum for that patient, whether it was a sore throat, or somebody that was having chest pain and thinking about an EMI or a PE, or different things going on.

Shellie Sulzberger:

So the landscape for all this current model is starting to change. They've never really placed a big emphasis on diagnostic coding. So your ICD-9 or 10 codes in the past. Typically, what has happened is if we could submit a claim form with an ENM code such as a 99213 or 99214, they've not really paid attention to say, "Does the diagnosis code actually correlate with that level of complexity?" They've never really looked at that. We submit a code, they would pay us, unless there were some bundling issues. So that's how the current model has been going for a while.

Shellie Sulzberger:

The future model though, is now where they're looking really at risk adjustment. And we know some payers have already started sharing this risk model. So some of the FQHC I work with, I know that their commercial payers are already starting to share in this risk adjustment with them. So we know healthcare is changing rapidly, and we know that more patients are affected than just our Medicare




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patients. So we do really need to work with providers on how to appropriately document and tell that patient story, as well as the work and what their differentials are and what they're thinking about. We know that documentation and coding is going to drive reimbursement, quality measures, et cetera, over the next few years.

Shellie Sulzberger:

So when you start thinking about risk adjustment and quality and value-based, you really have to think about, how does ICD-10 and risk go together, or does it? And you have to also ask, does your ICD 10 code really impact your overall documentation? So currently, diagnosis codes are used to calculate the patient complexity. So for example, if we put on a claim form that we have a patient that's a diabetic, but our next patient is an uncontrolled diabetic, so are diabetes with hyperglycemia, and they're on longterm insulin. If you're looking at those two claim forms hand-in-hand, we know that the patient, that the type two diabetic, uncontrolled on insulin, is definitely more risky, and there's a lot more thought process from the provider as the patient with just diabetes. Now what we have to teach providers is how important that is to actually get that in the assessment plan, so that goes on the claim form.

Shellie Sulzberger:

Because a lot of times what happens is, when I look at documentation, I will see somewhere in the history of present illness, or somewhere throughout the notes, that the patient's hemoglobin A1c was 10.9. They're on longterm insulin. But that never makes it to the assessment plan, which means if it doesn't make it to the assessment plan, it's not going out on the claim form. So the medical severity of the illness is really derived from what goes on the claim form. So as we start looking at these more risk-adjusted coding, we have to really make sure that we're getting the most specific diagnosis on our claim form. So ICD-10 is impacted not only by documentation, but ICD-10 and risk-based coding go hand-in-hand, which takes us really to clinical documentation improvement.

Shellie Sulzberger:

So this is also known as CDI. CDI has a direct impact on patient care by providing information to all members of the care team, as well as those on the downstream who may treat patients later. Clinical documentation has been in the inpatient study for many years. It's really just never made it to the outpatient clinics. So we have to really start thinking about how to implement a CDI program in our own health centers. And really, it's an initiative which we're focusing on improving our documentation, and how to take that documentation and keep it improved concurrently as we see that patient, each visit.

Shellie Sulzberger:

So organizations really need a well-rounded individual, internally, who can help really articulate the information to the providers, and do ongoing assessments, and educate providers. And we'll talk a little bit later on how to really implement this program, and how to start it and get it going if you don't already have one.

Shellie Sulzberger:

So when we're thinking about clinical documentation, we're looking at the effect on quality of care, we're looking at the acuity of the patient, we're looking at how to mitigate legal liability issues. So it's identifying your condition, by your spots in the documentation. So when we're reading the note, we're really looking to see what's the clinical picture of your assessment? What are you thinking about as your




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differentials? What kind of workup have you already done? If you've done workup, do we have the results back, and what are those results? What's the treatment that you're going to start? And if that treatment doesn't work, what's the next step? Our providers are great educators. They go in and tell the patient, "This is what I think is going on. This is what we're going to do. If it doesn't work, the next game plan is X, Y, and Z. If it does work, then here's the game plan."

Shellie Sulzberger:

But we don't always get that reflected in the documentation because we're putting a lot of pressure on providers to document more. We need it for HRSA, we need it for meaningful use. We need all of this information. So again, this is where we have to really learn how to look for a more team-based approach on clinical documentation improvement, and understanding what each team member can actually do, so that we don't have providers using information like the history of present illness for their coding if it's documented by someone else. So the better the documentation that reflects the complexity and the risk, obviously, it's either easier to explain the morbidity and mortality. So it's better if patient care, we know that.

Shellie Sulzberger:

Also, our documentation with better documentation and more information about that patient's condition, really provides a more accurate illustration of the acuity of the patient and the work that was done by the provider. Again, as I said earlier, if you go in the patient room and observe what that provider's done, a lot of times there's a lot of work done in the room, but it doesn't always get articulated on paper.

Shellie Sulzberger:

So what is documentation? So when you're thinking about documentation, we're thinking about a timeline. It's really a snapshot in time, of the health, as in contributing to that patient's care. It's also a communication tool. We use that communication tool for coordination and continuity of care between the provider and other providers, but also between the provider and the patient because more and more of our patients are receiving a clinical summary when they leave. So again, that's a communication tool between the provider and the patient. And also legal document. It really served that the care was provided. It's the proof in the pudding, if you will. So we have it for a legal document.

Shellie Sulzberger:

So we have to ask ourselves, why is documentation really so important? Well, we know it's critical for patient care and safety. It really describes what we did and what we told the patient. We use it for quality reviews, that information in your electronic medical record as all of our quality staff start talking to providers, so that they can abstract that information out. It validates that you provided the care. Sometimes patients forget that the service was provided. "I don't recall seeing Dr. Jones on that day," when they call the billing office. So it validates the care was provided. As I said earlier, it serves as a legal document. It also helps with compliance, if we have to port it to a payer to support the coding and billing. And of course if we have really good documentation and it's credible, it really reduces the rework of claims processing because we're not going to get as many denials if we're looking at medical necessity, and we're truly telling the story of that patient, and we're using the most specific diagnosis.

Shellie Sulzberger:




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So we have to remember to be very clear on what diagnoses or conditions are current. A lot of times, what we see is providers will list a slew of diagnosis in their assessment plan, but there's not really any information about it being current, or discussed during that patient encounter. And there's no indication that those tie together from the thought process of the provider. So it's really working with our providers from the documentation to say, "This is currently what's going on with that patient," the assessment plan. And maybe they have some historical diagnosis or medication that the provider is thinking about, to make decisions for today's current problems. So how do we tie those together? So we have to teach providers that diagnoses that are not being treated, and that are not being monitored during that day, or that are not affecting their decision-making, should not be pulled forward.

Shellie Sulzberger:

However, on the flip side of that, if those diagnoses are affecting their decision-making, or they're monitoring though them and looking at the medication and talking to the patient about, "Are you taking your medication as prescribed for your hyperlipidemia and hypertension?" Then to make sure that we document that information so everything correlates and ties together. Because when we are looking at all of the diagnoses listed, those are what's being taken into consideration towards the medical decision-making. So every diagnosis that's important should be documented as to what they thought about, and what they're doing with it. So it just goes hand-in-hand.

Shellie Sulzberger:

It's important that providers clearly document, again, everything that's being done to the highest level of specificity. Not just the primary diagnosis. I was just doing some training at a FQHC, and one providers said to me, "You know Shellie, sometimes I can list five or six diagnoses, but I know with my very first diagnosis, I have enough to support the level of service that I'm doing. Why is it so important that I document all five diagnoses that I'm actually treating?" Again, this goes back to the old model versus the model that's coming forward. In the current model, if you have enough for a level 401 diagnosis, you're going to get paid. They're probably not going to question that. But as we start looking more at the risk-adjusted base model, and they're looking at the severity of that patient's condition, things are starting to change with those quality initiatives. So it's really telling the story.

Shellie Sulzberger:

And I do understand the provider sides of the providers that are sitting out there saying, "Oh my gosh, do you already know how much I have to do?" I do. So you do have to find a happy balance to say, "Okay, what the happy medium to start this next step?" Because maybe today you're doing one or two diagnoses, but sometimes your patients have 12. So maybe say, "Okay, let's start small and let's focus on two or three diagnoses that are really important and really telling that story about that patient's condition."

Shellie Sulzberger:

Also, you'll see on the third bullet of this slide, MEAT. So it's really important. I want providers to really start thinking about the MEAT. And what that actually means is, we want documentation to show that the condition was monitored, evaluated, assessed, and/or treated. Again, I said earlier, a lot of times I'll see several diagnoses in the assessment and plan, but there's no information about how these diagnoses even tying in to the current condition or reason for visit. And there's no information as to what the provider thought about. So again, every diagnosis should show that there was some kind of monitoring, evaluation, assessment and/or treatment so that we can tie all of that information together.




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Shellie Sulzberger:

So now, looking at documentation, Medicare and most payers tell us that each documentation, each visit must standalone. So when they ask for our notes from May 17th, they don't want the previous notes, unless we have referenced something in that. Each note should stand by itself. So when we're looking at that, the documentation should clearly indicate why we're seeing that patient today. And then if we have code these conditions or other diagnoses, how do those impact the reason for visit? Or what was the thought process on, maybe the medication that was given based upon that patient's a diabetic or something like that. We're also looking to see on each progress note, if there's a problem list. Has it been updated? And if your problem was really accurate.

Shellie Sulzberger:

A lot of times what we find is, we build our problem list, patients have diabetes and chronic kidney disease, but as time progresses, and that kidney disease state changes from a stage two to a stage three, and the diabetes goes from controlled to uncontrolled, we need to make sure that we update our problem list. With an EMR, what happens is, we build our problem list, and it is time-consuming to update the problem list. So we tend to keep pulling the same information forward, even though it might not be the most accurate diagnosis. Every progress note should be signed by your provider. Print out your notes to make sure that everything's authenticated appropriately. Payers are starting to watch for cloning of notes. And really what that means is they're looking to see, "Are you taking the previous note and bringing it forward? And does it reflect any changes, or is it little to no change?"

Shellie Sulzberger:

If they find that we're cloning notes and there's really little to no change, they may view this documentation is not credible, and not medically necessary, and not supporting the service that was billed. So we have to think about cloning as well as templates. Templates help providers, but sometimes they can actually hurt providers. They should never replace the provider documentation. So templates are really a tool, just to give us a guide to start putting that information in. However, sometimes in this day and age when patients come in for a problem and we pull up a template, a lot of times, patients have multiple things that they're discussing. And so we can't always fit them in the template. And that's where providers do more work than they give themselves credit for, because they don't have a spot to document that information.

Shellie Sulzberger:

It's important as well, to make sure that we document the specific conditions and the medical records. So you'll hear me talk about that over and over again. So there's chronic or coexisting conditions. If they're important and they were discussed today, we need to make sure that they're actually documented. One of the things that I find a lot when I do chart reviews is really discrepancies in the medical records, and the reported diagnosis on the claim form. And what I mean by that is, as I said earlier, maybe the diagnosis is diabetes. The 11.9. But when you look in the medical record, it talks about the patient's uncontrolled, talks about the patient neuropathy, but we don't pull those down into the assessment plan. Maybe the patient comes in with knee pain, and somewhere in the documentation, we talk about the patient's morbidly obese and their BMI is pretty significant, and we go through how they should reduce their weight and diet and exercise. But that morbid obesity and the BMI don't get pulled down into the assessment plan to really tell that story about that patient's knee pain.




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Shellie Sulzberger:

Also, we need to know if the condition is stable or worsening. Providers are really good about putting the diagnosis in the assessment plan, but again, it's not always to the highest level of specificity. Or, sometimes a coder can't tell if that condition is better, or is it worse? Maybe you're changing a medication but they don't know why you're changing the medication. Or There's a historical diagnosis, and it's really unclear, "Does the patient currently have that problem, or is that a history, as it's no longer active?" Other documentation issues that we find is, the documentation's not authenticated. So that's why I said it's really important to print out your notes because what a provider sees in the EMR is not the same as it looks when you print out the note on paper.

Shellie Sulzberger:

And then we find that providers use nonstandard abbreviations. So you might see an up or down arrow, maybe mean increased blood pressure or decreased blood pressure, but we don't always know what those means. So providers really need to make sure that they use abbreviations that are appropriate, and not symbols as well.

Shellie Sulzberger:

So let's talk about some examples of documentation we currently see and maybe documentation that might be a little more specific. So if you look on the left side of the slide, COPDT - continue meds, history of Angina - continue meds. Diabetes, increased insulin and neuropathy. This would be a typical assessment that we see and plan. However, to the right, as we move again towards more value-based and more risk-adjusted coding and documentation, we're starting to look for more information. COPD is stable. It's controlled with Advair. Angina, stable on the nitroglycerin. Diabetes type two with hyperglycemia, we're going to increase their insulin. Diabetes type two with polyneuropathy, and then longterm insulin. So our claim forms should have the COPD, the Angina, type two diabetes with hyperglycemia, type two diabetes with polyneuropathy, and longterm insulin.

Shellie Sulzberger:

So you can tell them the right, it gives us a better picture of everything that's going on with this patient, and the risk factors. When the patient's on longterm insulin and they're type two diabetics, our providers are thinking about the lows and different things that are going on with that patient. When they have neuropathy in they're in control that patient is more ready than a patient that's diabetic, that's not uncontrolled. So again, it just tells us about our story. It's teaching our providers how to document this information to get somebody else that's not a clinician that's not in their world every day, to understand how significant the risk is to that patient and the work that was performed.

Shellie Sulzberger:

So depression. Major depression, single episode, is it mild, is it moderate, is it severe? So again, providers are in the habit of just documenting depression. We need more information as to the type of depression. Is it a single episode or recurrent? Is it mild, moderate or severe? And if it's severe, is that with or without psychosis? So again, this goes back to education. We need our coding and billing team to spend time with our providers and educate them on the most specific diagnosis. Diabetes and chronic kidney disease. We want to see that it's diabetes type two, uncontrolled with chronic kidney disease stage three, instead of a diagnosis of diabetes and chronic kidney disease. Asthma. We want to know what type of asthma it is. For example, mild persistent asthma. Also, the patient has a history of smoking. That is important to know, from the coding and billing side, as well as the risk factor. So if the




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patient is an asthmatic patient and they have a history of smoking, that impacts the risk of that patient. So it just tell us a better story of what the provider is thinking about, and the risk of that patient.

Shellie Sulzberger:

So related to behavioral health, behavioral health providers have always been pretty specific in their diagnosis, and their documentation because they have always used the DSM coding. So with behavioral health, we can include other medical disorders that impact the mental disorder that's being treated. That hasn't always been an impact in the past. They're really good at their specificity on their diagnoses. But we know that behavioral health providers are really looking at some of the medical disorders, and the medications those patients are on. So again, just tying that together, what is the provider thinking about, and how is it impacting their decision-making?

Shellie Sulzberger:

Let's look at an example. So a patient seen for depression and generalized anxiety disorder, no symptoms of psychosis, but the patient's severely depressed. Patients that recently abusing alcohol subsequent, to the onset of the depressive symptoms, the patient's had two anxiety attacks in the last month, and having marital problems. Patient also lost her job due to poor performance and absence. Her past medical history reveals that she has the treatment for hyperthyroid and hypertension.

Shellie Sulzberger:

So when we're looking at the diagnosis, we want to know if the patient has a major depressive disorder that's recurrent without psychotic features. She has a general anxiety disorder, alcohol abuse, and currently we don't know if it's complicated. So we would use an uncomplicated code because there was not enough information to give us any detail on the alcohol abuse. Hypothyroid, hypertension, problems in a relationship with a spouse or partner, and unemployment. So if you are a payer and you received these diagnoses, you can tell that there's a lot going on with this patient. The provider is not only thinking about their depressive and anxiety disorders, but also their medical disorders that play a part in that as well as their social factors and the economic standpoint of the relationship issues, as well as the unemployment issues. So it's just making sure that we clearly document that information, and put it on the claim form to adequately reflect the severity of the patient's overall illness.

Shellie Sulzberger:

Okay. So we're going to open up to a polling question, and what I really want to know from you now is, are you currently doing any clinical documentation improvement reviews in your health center now? Yes you are. No, or you're unsure. Okay.

Sherry Gimmer:

Awesome. Thank you Shellie. And for folks that may have joined a little bit late, and didn't get the logistics for the poll question, the poll question is located in the lower right hand side of your computer screen. All you have to do is click your response, and make sure you hit click 'submit', so we do receive that response. We're waiting for about 10 more people to vote. So we're going to close in about 15 seconds, if you wouldn't mind submitting, so we have the most accurate results to share with everybody. Awesome. Let me go ahead and close the poll and submit the results. And Shellie, you should be able to see it now.

Shellie Sulzberger:




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I can. Thank you. So it looks like that we have 20 out of 44 that are currently doing CDI reviews. Nine out of 44, so about 20% are not doing CDI reviews. And then eight out of 44 which is about 18%, aren't sure, and then we had about 16% to 20% with no answer. So let's talk a little bit about CDI reviews for a minute. We'll go into a little more detail. If you're doing CDI reviews in your practice now, one of the things to remember is, you have to start small. So don't try to look at every diagnosis. Run your top list your, diagnosis, maybe run the top 25 chronic conditions and then talk to the providers about which diagnoses are most important to them. And what you need to do is come up with some kind of documentation tool of what you would expect to see documented.

Shellie Sulzberger:

And again, I think this is where you have to work with your providers to figure out what they are asking the patients, what's important to them, and actually what they're looking at, in asking that patient. So if you take COPD for example, some of the causes of that could be, inhalation of smoke or chemicals or emphysema. So what we're wanting to know from that is from a documentation's needs, if somebody has a COPD patient, do they also have acute bronchitis? If so, we want to have this documented. Or are they having an exacerbation? If they are, again, we want to make sure that's documented. What other kinds of lung disease do they have? What's the etiology of this acute event? What caused the exacerbation? So again, I think just working with your providers on documentation needs, as well as any co-morbidities that they're thinking about, as you can work with those providers hand-in-hand.

Shellie Sulzberger:

The biggest problem we see with CVI is, a lot of times it's done on the backend, but the information is not relayed back to the providers. So they don't know what's missing. They don't know when they're doing a good job. A lot of times providers say, "Well, I guess we're doing a good job Shellie, because I don't hear anything." Well, that doesn't always mean that that's the case. And we know the coding and billing staff is really busy as well. So again, it's getting your team together. So we need to provide, or we need a coder and/or filler. We need one of the clinical staff, whether it's the nurse or the MA or if you have a patient care tech, but everybody to hear the same things. Because as you're doing huddles, if you're doing those, if you're not, you shouldn't be doing those, as you're huddling in the morning and you're looking at that patient list of who's coming in today.

Shellie Sulzberger:

If I'm the nurse for Dr. Jones and I know the coding and billing team have said, "We're really focusing right now on diabetes, anemia and chronic kidney disease. Those are three that we're really working on." I'm going to be looking at those patients so that I can tell Dr. Jones, "We've got four patients coming in today." So we really need to focus on documentation of those conditions in these four patients. And then reminding Dr. Jones, "Hey, I have Mrs. Smith in room two and she's got diabetes and chronic kidney disease, so make sure you document to the highest level. We know the providers are doing the work in the room. It's just teaching them and reminding them to articulate that information on paper. So again, it's bringing that team together because our providers get busy, our clinical staff are busy, and our coding and billing staff are busy, so everybody's busy.

Shellie Sulzberger:

But we need to learn how we can tie it together. Because if the coding and billing team can remind the clinical team and the providers, and then the clinical team can remind the providers that morning and as they're rooming the patients, we do that enough times and then our habits start to change. So as long as




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we continue that, we can make that habit become an ongoing reality. But when we're only doing it once in a great while, the providers will do great and the clinicians they'll do great for a few months, and then they'll go back to their old ways because they don't hear from us again. So we need to remind the providers when they're doing a great job, but also give them some examples where we need a little more information to tell that story.

Shellie Sulzberger:

So before we go on, Liz, do you want to see if anybody has any questions yet before I move on?

Elizabeth Zepko:

Hey Shelley, we don't have any questions right now, but for folks that were late joining the call or just need a friendly reminder, we are taking some questions in between certain sections. We're going to carry most of those towards the end during the last 30 minutes. So please feel free to submit your question and we'd love to answer it, in the Q&A box. It's located in the lower right hand side of your computer screen. Yes it is a box that says Q&A. So if you've expanded your screen, you'll need to minimize it to answer that question. So just make sure you type that in and hit submit, and we will answer in the order of a the way the questions come in. So feel free to take it away, Shellie.

Shellie Sulzberger:

Perfect. We'll move right on to documentation. So the history of exam and medical decision making are the keys for not only the patient encounter, but also for the coding and billing side as well as the documentation. So when we're thinking about those key elements, they should be concisely described in the note. We want to know from the provider, what did you think about each issue? What was the thought process? What did you do about each of those conditions? What do other people need to know about each of those conditions? And then what do others need to do about each of those issues? So again, we're thinking about the thought process, what was done, what we need to know, and what do we need to do? So tying each of those diagnoses, if you go back to the MEAT, and then about, again, what did you think about, what did you do, what do you need to do later? So going through all of those together, and really documenting that information.

Shellie Sulzberger:

So what does clinical documentation actually facilitate for the patient, physician and the health center? So for the patient, it's quality of care was provided. It also shows them the continuity of care. When we don't do a great job of documenting and submitting our claim appropriately, it could result in a nonpayment issue by the insurance company. So our patients will end up getting a bill. So when we're thinking about medical necessity, if you do minor procedures in your office, if we're not documenting to the highest level of specificity, that patient may receive a bill from the insurance company, indicating that the service was not considered medically necessary, which means that they will owe that payment. So again, it impacts our patients, not only from the continuity of care and quality, but it could result in a nonpayment.

Shellie Sulzberger:

For the physicians, it really impacts them for accountability. Also for performance management, and again, in payment. So as we're moving into this new model, we're starting to see where providers are getting what they call health grades. So patients can go out and Google your provider, and there's going to be health grades on there from these quality initiatives that payers are starting to do. And so you




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could have the best doctor in your practice, but maybe the documentation is not stellar. So it could show that this provider doesn't appear to be a great provider because of his health grades. So again, just it demonstrates accountability, the performance management, and then it could impact the payment.

Shellie Sulzberger:

And then of course, your health center is definitely impacted, again from the payment, because it's based upon our coding and billing, and then the documentation, if it's not clear and credible and concise, and really to the highest level of specificity, it may not support the services and treatment that were actually rendered. Which means, then, we may not receive the appropriate reimbursement. Or they may reimburse that, and after they do some probe audits, they may pull back some of that reimbursement that was already given to us because the documentation is not to the highest level, or it's not credible and clear.

Shellie Sulzberger:

So templates. I talked about templates a little bit earlier. Templates are a good source to help providers. They're kind of just a shell, if you will. The problem with templates is that, number one, they don't always give us room for all the information that's performed and actually done in the room, because templates tend to box us in. So our templates may miss documentation even though it was actually performed because the provider can't find a spot to put it. It's convenient of course, to re record like normal review of systems, or normal exam findings. But sometimes it's really clear as to what you examined. It might say, "Cardiovascular, normal," but what did you actually examine? Or under review of systems, it might say that the review of systems for IDNT, cardiovascular, respiratory were all normal or negative, but we don't know what questions you asked.

Shellie Sulzberger:

For respiratory, did you ask about wheezing and shortness of breath? Or did you only ask about shortness of breath? So sometimes templates are not very... They're convenient for the provider, but they're not very detailed. A positive, is that they do prompt the provider to document information that they're actually doing. However, they can be easily abused by practices just checking off boxes, and we check off boxes. And one of the things with templates and checking off boxes, and not really looking at our notes is, if your medical assistant or your patient care tech, somebody who's going through the review of systems and we're marking everything negative in the review of systems, however, my history of present illness indicates that I come in with wheezing and shortness of breath and I'm having difficulty walking, but all of my systems are negative on musculoskeletal and respiratory, now our documentation's not credible. So payers start to question, "Did you really go through the review of systems or did you just click a box?"

Shellie Sulzberger:

So those are sometimes, things that are easily abused. Or on the exams with templates, sometimes the exam is brought forward, and then you find either that the exam doesn't correlate, or there's a piece of the exam that's missing. Maybe the patient presents with back pain, but that's not part of the template exam because they came in for other things as well. But in the HPI, the patient complains of back pain, and then we don't have an exam of the back. So again, our templates can be easily abused and we start questioning credibility on those. When we also think about credibility, we also look with template, if the patient comes in for a cough, but you have 14 point review of systems at a head to toe exam. That may be questioned on, if it was medically necessary to do all of those. Did we actually do all of those, or did




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we click the button and just mark them as all normal, and go back and fix the ones that were abnormal? So again, credibility is looked at as well as the abuse of the templates.

Shellie Sulzberger:

So when you think about diagnosis coding, and earlier I asked you, does ICD-10 diagnosis coding correlate with risk and payment? So if you're thinking about chronic conditions, and medical-decision making, it does allow us to offer better health management if we're documenting our chronic conditions, and how those impacted your thoughts today. Because all the diagnoses are taken into consideration in the medical decision-making, as long as it's documented somewhere in the notes that those were... Again, we had the MEAT of it, the manage, they were evaluated, they were assessed, and/or treated for each of those chronic conditions. So what we're finding is more and providers are starting to look at those chronic conditions during the patient's either annual wellness visit, or at their physical, depending on if they're Medicare or if they're commercial payer. But a lot of times every year, we're going through each of those. So again, just making sure that we're documenting the chronic condition, but showing that we evaluated it, we managed it, we assessed it, and/or treated that condition.

Shellie Sulzberger:

Because complete and accurate coding practices really minimize the administrative burden of additional paperwork. Payers are starting to ask for more and more notes. They're starting to look at our coding to say, "Gosh, you build a level three and you have 12 diagnoses? That doesn't make sense." Or, "You have a level four, but the very first diagnosis is a cough, and you don't have any additional information," because we forgot to put on there that that patient's a smoker and they have COPD, and they have emphysema. We didn't tell the story. So payers are starting to say, "Hey, before I pay you, let me look at your note." So again, time is money. And every time we touch that claim, it cost us money. So again, it's just bringing all of that information together.

Shellie Sulzberger:

So we were thinking about documentation of the conditions as chronic medical conditions, or they're acute problems. Medicare tells us that all medical conditions that are evaluated and/or treated during your exam today, should be documented, and they should be recorded on the claim form. But again, they're telling you that if they're not documented as far as like monitoring. So more thinking about monitoring, what kinds of signs, symptoms, disease progression, disease regression, what kind of evaluation did you do? Was it medication, was it test results, did you look at the effectiveness of that medication? How were they responding to the treatment? Did you assess or address those? For example, did they have any tests that you ordered or reviewed? Did you discuss it with the patient? Did you counsel them? Or did you treat them? Did you order medication? Did you order therapy or other modalities, maybe PT, et cetera? So again, thinking about the conditions a patient has, and then did you really go through and do the MEAT, the monitor, evaluate, assess and treat each of those individually?

Sherry Gimmer:

Shellie, this is Sherry. We have a question. I thought it would be good just to answer it at this point.

Shellie Sulzberger:

Sure.




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Sherry Gimmer:

The question is, in the review of systems, is it okay that providers put, and hopefully I have this right, as noted in the HPI?

Shellie Sulzberger:

Great question. So the question is, in the review of system, can the provider indicates as outlined in the HPI? And that is perfectly acceptable. The one thing that I would remind providers and the coders and billers as well, when you're looking at those notes to make sure that there's actually a review of systems in the HPI, a lot of times when I do a chart review, the providers will say, for example, the HPI patient is care today with the right knee pain that's been going on for three days, it's eight out of ten, it's sharp and achy. They'll get to the review of systems and say, "As outlined in the HPI..." And so I'll look in the HPI, but there might not be reviewed a systems up there.

Shellie Sulzberger:

So Medicare and most payers follow the same guidelines. You can put the information anywhere in your medical record, as long as it's documented. So we would expect with that same scenario, patient denies any numbness or tingling. No fever, no shortness of breath. Now we would have to review of systems outlined in the HPI. But either place is acceptable.

Shellie Sulzberger:

Okay. So diagnoses. Again, the documentation should clearly indicate the type of condition. Is it an acute condition? Is it chronic? If it's chronic or acute, do they have an exacerbation? If so, is a mild or moderate? Diagnosis can't be assumed. So coders can't look through the record and say, "Oh, the patient's diabetic because the provider put that in their assessment. But their hemoglobin A1c is 13.5. So I know it's uncontrolled. Payers or providers are the only ones that can diagnose the patient with diabetes, uncontrolled or with hyperglycemia. Coders, billers, clinical staff cannot diagnose patients. So we rely on the providers to give us that information to the highest level of specificity.

Shellie Sulzberger:

So when we're educating providers, we want the provider to clearly identify the condition or diagnosis. So, demonstrate the prognosis and the progression of that problem. Outline any kind of clinical indicators that you're thinking about, because a lot of times, there's a discrepancy between the diagnosis code that was billed, and what's actually written in the medical record. So again, we want the providers and the coding and billing team to work hand-in-hand. And we need to find out if from the coding and billing side, is it an EMR issue when there are discrepancies? So for example, when I was looking at a provider in a FQHC and doing the documentation review, the coder said, "The provider is always reporting this unspecified ankle pain diagnosis."

Shellie Sulzberger:

So we got in and looked and we talked to the provider. While the provider's EMR showed right left bilateral ankle pain, but it was leaned to an unspecified code. So when the provider's mind, they were picking the correct code, however, the EMR hadn't leaned in correctly. So the first thing that coding and billing teams should be looking at is if we're using unspecified ICD-10 codes, they need to look and see if linked incorrectly in the EMR, or is the provider just picking the incorrect diagnosis? So then we know where to educate, because I don't want to spend a lot of time educating the provider if they're picking




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the correct code based upon the documentation that's in the EMR. So if it says left ankle pain, but it's linked to an unspecified code, the provider is doing the correct thing, they're finding the right left or bilateral, and we need to work with the EMR company or IT, to make sure that it's linked correctly.

Shellie Sulzberger:

Also, working with the provider to document the plan if it's not clear. We want to make sure that the plan of care is clearly documented. What did we tell the patient? What's the game plan? When is the patient going to come back? And when they come back, how did they respond to the treatment plan from the previous visit? So again, tying that all together, it should tell a story.

Shellie Sulzberger:

So when I educate providers, especially in an FQHC, most of them tend to bill 99213s, then when you meet with them, they always say, "Gosh, I'll have the sickest patients. My patients are diabetic. They have congestive heart failure. They've got emphysema. They've got COPD, hyperlipidemia." But what happens is, if providers are not billing correctly, or they're not documenting correctly, or sometimes they'll a 99214, and it goes with maybe a diagnosis of like sinusitis. And when you meet with them, you go, "Oh my gosh, this patient is a total train wreck." But that's not clearly documented in the medical record. So tell me how that impacts your thought process for today, with that sinusitis. If this patient's a train wreck and they came in for sinusitis and they're diabetic and COPD and CHF and they're noncompliant, tell that story in the medical records, and clearly make sure that you've diagnosed and assessed all of those diagnoses, and put them on the claim form.

Shellie Sulzberger:

So again, it's just tying everything together. That clinical evaluation, what kind of therapeutic treatment did you do? Are there further diagnostic studies, procedures that you're ordering? Are you sending them somewhere else for referral? So just really tell that whole story. So when we're looking at documented to the highest level specificity, again, I said start small. Diabetes. We want to know is it type one or type two? Or is it drug or chemical induced? Is it due to some underlying condition? When we're thinking about control, we want to know, is it controlled? Is it out of control? Do they have hyperglycemia, hypoglycemia, are they a type two diabetic on insulin? That's going to be really important from a coding perspective, as well as for the risk of that patient, and the work of the provider. What other kinds of diagnoses and conditions do they have that are impacting their diabetes and your thought process for managing their diabetes? What kind of manifestations and complications does that patient have? Do they have circulatory issues? Do they have ketoacidosis? Do they have neurological issues? Do they have kidney complications? Do they have skin complications? So again, what kind of complications or manifestations do they have?

Shellie Sulzberger:

And then when you're looking at those manifestations, really start to think about the cause and effect. Type two diabetes on longterm insulin with polyneuropathy. So again, it's just making sure that the providers are documenting that information. So this is where it comes hand-in-hand with our coding and billing staff, and our CDI staff. Have a plan. If we're looking at diabetes, make sure that we're looking at each of these things. Do we have the type, do we have the control, do we have... Whether they're on insulin or not. Do we know what kind of conditions and diagnoses are associated with their diabetes? Do we know what kind of manifestations or complications they have? So we have something to look at,




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from a documentation as well as what we expect as a health center, so then we can go back and educate our providers.

Elizabeth Zepko:

Shellie, I don't know if this is the place, but we do have a question related to asthma. Would you like to wait on that one or would you like to answer it now?

Shellie Sulzberger:

I can probably answer.

Elizabeth Zepko:

Okay, perfect. It says, "We as clinical staff review our asthma patient charts that have unspecified diagnosis and medication the patient is taking, and adjust it to a more specific diagnosis based on the medication they are taking. Is this okay?"

Shellie Sulzberger:

What staff is adjusting the diagnosis? Coding staff?

Elizabeth Zepko:

It says clinical staff review.

Shellie Sulzberger:

So if I'm understanding the question correctly...

Elizabeth Zepko:

She listed nurses and medical assistants.

Shellie Sulzberger:

Okay. So only providers can diagnose me, as a patient. So if I'm an asthmatic patient, we need the providers really to specify the type. If I'm mild, moderate persistent, intermittent. My gut says the provider should diagnose me. I would have to see maybe an example, and if my contact information is at the end. So the person that asked that question, if you want to maybe send me an example, but just make sure that you remove the PHI out of there, so no patient health information, and no patient name. Maybe just copy the assessment plan and maybe the HPI, and then what the provider reported versus what it was changed to. That might help me so I can look at it and give you a more accurate answer.

Elizabeth Zepko:

Thank you Shellie.

Shellie Sulzberger:

You're welcome. Okay. So diabetes, again, this is just going to give you an example of what we just talked about. Type one versus type two, specifying if the patient's hyper or hypoglycemia, any kind of body system. So just internally, create expectations based upon the disease. Like what kind of documentation you expect to see. And I think you definitely need a provider on board with this, because




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they're the ones who know the clinical aspect. So internally, create your documentation, expectations so that when you're doing a review, so if diabetes is one of yours that you're going to look at from a CDI perspective, you need to have some kind of expectations, so that we're following the same thing, that we're asking the providers to do the same things.

Shellie Sulzberger:

And then you're going through to see if this information is documented. That way, when you meet with the provider, you can either say, yes you have the type. "Here it is. It's type two. You told me that they're on control. You told me that they have polyneuropathy as well as chronic kidney disease. They're on longterm insulin." You back all of this criteria, versus the next provider, "You didn't tell me if it's type one or type two, and you didn't indicate that they have any neuropathy. But in the HPI it says that the patient has numbness and tingling in their feet. But you didn't tie that together to tell me yes it is neuropathy based upon their diabetes." And it gives you a guide as a CDI individual or coding and billing individual. And then it gives our providers some accurate information to follow.

Shellie Sulzberger:

So when we're thinking about depression, we want to know, is it single or recurrent? So the opposite of care. We want to know if it's mild, moderate, severe. If it's severe, is that with psychotic features or without? So the severity of the depression. Is it partial remission or full remission, if applicable? And then any other associated diagnoses or can that impact the depression. So do they also have some anxiety or stress-related factors? So again, just tying in, again, the episodes, the severity, if they're in any kind of remission and other associated conditions or diagnoses with that.

Shellie Sulzberger:

When we're looking at chronic kidney disease, the diagnosis of chronic kidney disease cannot really be coded from diagnostic reports. Again, the provider needs to specify that the patient has chronic kidney disease. Where we can use the diagnostic reports for like the GFR and things like that is when you're setting up your CDI program, and you're putting that information of what we expect. The providers can go through and say, "Okay, if the GFR ranges from this to this, and we have at least two lab tests to prove that, this patient is a stage two or stage three." Doesn't mean that we're going to change it on the claim form, but this will allow your CDI program and staff when they meet with the providers to say, "Dr. Jones, you indicated chronic kidney disease, unspecified your assessment plan. But we looked through the last two labs and based upon our internal protocol, you providers are telling us that with this GFR, this patient is a stage three, but you didn't document that information."

Shellie Sulzberger:

So you can use your CDI program like that for the providers to give us some guidance based upon the standards of care. Same with diabetes. If the hemoglobin A1c is XX, it's going to be uncontrolled. Or chronic kidney disease with hypertension. So again, it's just setting up that criteria. It's also making sure that our coding and billing staff read the official coding guidelines every year. So the official coding guidelines tell us that chronic kidney disease and hypertension, ICD-10 guidelines tell us that they assume there's a relationship with the patient has both chronic renal disease and hypertension. So we have that cause and effect. So your coder can code hypertension with chronic kidney disease, even if your provider doesn't specify how that cause and effect link together. But the guidelines tell us that they assume the relationship. So it's making sure that your coding and billing staff understand when they can code those together, and when they can't have that cause and effect or presumed linkage. And then




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when we can't have the assumed linkage, then we need to make sure we educate our providers to document that information.

Shellie Sulzberger:

So preventative visits, this is a great time to capture those chronic conditions. So really looking at that whole patient, all of their care. This allows, again, for quality and risk adjust based coding. Many of the payers are going to make sure that it's documented at least once a year. So during that annual evaluation, that's when we would want to see documentation and submission of all relevant diagnoses, and corresponding diagnoses is important for that patient care. Number one, it promotes the quality of care. It promotes the work that the provider was performing. It helps to make sure that we have all the screenings we have done, and ordered, and it gives you that ongoing assessment of that patient's chronic conditions. So it helps, overall, give us that accurate patient risk score calculation. So what we're looking at that risk-adjusted coding, it gives us that calculation based upon this corresponding diagnosis and promoting all of that care. And it helps the provider as well, to make sure that they are up to date on everything and everything is planned, ordered or received back on that patient's care.

Shellie Sulzberger:

So when we're looking at this annual visit as well, again, just documenting the current conditions, go through the MEAT of it to do, monitor, evaluate, assess and treat. And then if they're continuing on medication, that's to treatment plan. You can just indicate, continue on that form, or whatever the treatment plan is. This allows you as a provider as well, to make sure that we've conducted any kind of preventative screenings, if the patient doesn't have those diagnoses. Make sure that we're up to date on a preventative measures. Patient had their pap smear, their colonoscopy, their mammogram, et cetera. Gives you a chance to go through and review medication, and really to make sure that we've really evaluated that patient from head to toe. So it gives you the opportunity to identify any gaps in care and create a plan for the ongoing year.

Shellie Sulzberger:

So documentation and medical records facilitate several things. Number one, patient care, because it allows you as the provider to evaluate and plan that patient's immediate treatment, but also to monitor their health over time. So it's not just today, it's ongoing monitoring. It allows you as a provider as well to communicate that continuity of care between you and other providers, but also between you and the patient. As I said earlier, we're giving them a clinical summary, so it allows us to give that information to communicate with the patient once they leave. Reimbursement. Of course, it allows us to have accurate and timely claims review, as well as accurate and timely payment. Documentation also is a profiling method. It allows utilization review of quality care evaluation. And then of course, data integrity. We know that they use the data from our EMRs to codify for research and education and patient safety, et cetera.

Shellie Sulzberger:

So when you're thinking also about documentation, you have to think about what's the patient's clinical picture during your visit today, and your assessment? So identify the condition about your thoughts, it gives the other people, whether it's the patient or other providers, or payers, an idea of what you're thinking, what kind of workouts you're doing, what's your differential diagnosis, what workup's already been done, where are those results and what are we going to do next? If there's any kind of treatment plan that started. So the better the documentation that reflects the complexity and the risk, obviously




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it's the easier to explain the morbidity and mortality of those patients' conditions, the likelihood of liability claims being frivolous is definitely reduced.

Shellie Sulzberger:

As we all know, if it's not documented, they say it didn't happen, which we know is not really true. But if it's not documented, we just really can't support it. So when we go back to documentation, if it's not documented, then it allows somebody to think that the work was not done. So even if we provided excellent patient care that day, if we didn't document it, it's going to be really hard to support that. And that's where we're looking at, again, those risk-adjusted-based calculation, and those health grades that are going to start being published.

Shellie Sulzberger:

So when you're looking and seeing a patient, number one, you have to know why are you seeing the patient. This is working with your medical assistants. We don't want them to document that the patient's here for follow up, or med refills. That is not why the patient's actually being seen. They may need medication refills, but they're actually being seen for their chronic medical conditions. So it starts with training with your scheduling staff, your medical assistants, the coding and billing staff, so we all work together. So your medical assistant staff needs to really document why is the patient being seen today? This is going to fall in line by the history of present illness. It's going to be driven by again, why that patient's being seen. The providers are the only ones that can document the review or the HPI.

Shellie Sulzberger:

So the HPI has to be documented and performed by the billing provider. Your review of systems can be documented by the clinical staff, so your medical assistant. So medical assistants can document why you're seeing the patient, a pertinent review of system, and past family/social history. The billing provider has document their own HPI, their own exam, and their own assessment plan. Now, the only time that that would differ is that you have a scribe. And a scribe is somebody that sits in the room with you, and documents, verbatim, what you as a provider says.

Shellie Sulzberger:

So when we're looking at that history of present illness, we want it to be detailed based upon that chief complaint. And then we want the provider to review the review of systems that it was taken by ancillary staff to make sure that there are any positives, what do we need to address on those? Or if anything was forgotten, we need to include that information. And then our exam is driven by, again, why the patient is being seen, but also their HPI and permanent review a system. So if I have a review of systems that's positive for shoulder pain, I would expect to see an exam of the shoulder documented. And then our assessment and plan correlate from, again, the history and the exam. So your assessment documents, your diagnoses or signs or symptoms or anything that's impacting your decision making. And then the plan is just going to outline the treatment for that condition, whether it's medication, diet, lab referrals, et cetera. And when the patients should follow back up with the provider.

Shellie Sulzberger:

So you can see here, from a documentation perspective, it's the core of every patient encounter. So it's really the middle piece there. Clinical documentation in your medical records has to be meaningful and accurate, has to be timely, needs to reflect the scope of the services that were actually provided. It's going to take your entire team to work together to make sure that we collect and provide meaningful




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information throughout the patient's continuity of care and in the actual documentation. So again, it's working together as a team. What do we expect as a health center? How are we going to get that information? But then we have to provide education back to our providers and back to our clinical team.

Shellie Sulzberger:

So when you think about providers, we have to think about what's the providers view, right? So most of the providers say, "Shellie, I'm a doctor. I'm not a coder. I want to take care of my patient. I don't have time for all this busy work that just benefits the insurance company. Why can't I just send them all of my notes? Why do I have to report every single diagnosis. Can't they read the notes?" So the providers really want to take care of their patients. That's what they went to school for. So we have to learn how to make it a little bit easier. How do we engage providers to perform accurate documentation, and really telling the story of their patients, so that we can make it a little bit easier? How do we take some of the burden away to give them time to add adequately and appropriately document their patient's story?

Shellie Sulzberger:

Also with the providers. They're aware of the value of their billing codes. They understand billing and the ICD-10 codes. They know what CPT and ICD-10 codes. They're also aware of morbidity and mortality rates. But we just have to start reviewing and educating them about their documentation. Providers learn best from their own notes, so while still being like a coding and billing education in a group is great, but the best way for providers to learn is pull five of their notes, go through and look at not only the coding and billing, but the overall documentation. Is it credible? Does it make sense? Does it all match? Did they document everything they did? And sit and meet with them one-on-one and go through these items. Look at the medical decision-making. Does the medical decision-making support a higher level of complexity, but the history and exam are lacking maybe for a higher level of code? Maybe they reported the correct CPT code, but they didn't appropriately document the history or exam, based upon the complexity of the patient.

Shellie Sulzberger:

Sometimes providers say, "Shellie, I'm just going to bill a low level. That way I don't get in trouble." Providers are starting to watch for that as well, because it's just as wrong to under-bill and under-code as it is to over-bill, or over-code. And we're starting to see where, payers are looking, and especially attorneys are looking to say, "Gosh, did you not provide that patient adequate care and treatment because they are under-insured or not insured at all?" Because we're building low level.

Shellie Sulzberger:

So we need to learn how to accurately document and bill appropriately and providers do look at the patient and try to determine if they can afford that care. But really, we want the provider to stay out of the money. We want them to bill for the service that they actually performed. You'd have a sliding fee schedule. We can work with payment plans in the back. So let the administrative staff work with the patient on how that bill is going to be paid, and the provider should just document and code appropriately. We have to start educating our providers on the complexity of their decision-making, and how that reflects the complexity of the patient, and the term that they use to really lead to the correct code assignments.

Shellie Sulzberger:




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Okay. So I'm going to open that up to the last polling question. Does your Coding and billing team meet with the providers to go over documentation? And if they do, do they meet individually with the providers? They provide group education with providers. They send emails or jelly beans? The providers encoding and billing staff really don't communicate now, or you're unsure. And if they do, the individual group or the jelly beans, if they do all three of those, pick the one that they do most often.

Elizabeth Zepko:

Okay. Shellie, I'm going to close the poll in about 10 more seconds. I've got about 10 people still waiting to submit their response, and I want to make sure we gets things as accurate as possible. And as those last people are submitting their responses, I just want to remind folks, thank you so much for your questions. We do have a few in the queue. If you have not submitted a question just yet, now is the time. There's a Q and a box located in the lower right hand side of your computer screen. Again, please do not place anything into the chat unless it's a quick comment for us as panelists. But please, if you have questions that you would like to answer, please use the Q&A box. Just type your response and hit submit, and we will answer them as we're going along. But again, we're about to get into that Q&A portion at the end of the webinar. So Shellie, you should be able to see the responses now.

Shellie Sulzberger:

Great. So it looks like 20% say they meet individually, about 9% provide group education, about 30% send emails or jelly beans, about 9% say they don't really communicate, about 9% unsure, and then about 23% did not answer. So when I look at this, I figured maybe the option C, emails or jelly beans, was maybe going to be the highest, which is what I typically see when I go to an FQHC. And the coders and billers are frustrated because the providers don't reply. So providers get so many jellybeans and so many emails, eventually they stop responding. They don't really understand the importance. So again, it's meeting with each of your providers to find out how they want the information articulated to them. If you have a question, is it best to meet with them on their admin day? Maybe if their admin days Friday at 9:00 o'clock, every Friday at 9:00 o'clock or every other Friday at 9:00 o'clock, you go meet with them for 10 minutes.

Shellie Sulzberger:

Again, working with our coding and billing staff to be organized and to have everything in order, and how to communicate with that provider, and the importance of the meeting. Because when we send emails and jelly beans and they quit responding, it holds up billing. The providers get frustrated, and the coders get frustrated. So again, it's figuring out the best way. Individually and group are the best way to educate our providers. They learn best from their own notes. The group education is very beneficial, so everybody can hear the same types of question.

Shellie Sulzberger:

So I'm going to go to the next slide. We're going to talk about how coders and billers can actually help providers. So first of all, when we're thinking about the coding and billing staff, in most of the FQHC, they are verifying the diagnosis code selected. Not always, but some of them are looking at that. So again, if the diagnosis code selected is not to the highest level of specificity, and it is documented to a higher level, the coders can update that diagnosis accordingly, as long as it follows your health center's guidelines. Assigning codes, if a diagnosis code was missed. Again, it's appropriate if we're doing some Q&A on our coding and billing staff, and as long as it follows your guidelines.




Page 22 of 29

Shellie Sulzberger:

What you have to think about as a health center is, we don't want to hold up claims, waiting on a provider to give us a diagnosis. If your coding and billing staff can find the diagnosis that's appropriate, and if you, as an organization, are doing some audits on your coding and billing staff to make sure that what they're selecting is accurate and correct. So it's just like our providers, we should be doing audits on our coding and billing staff, as well as our providers. So then when you get to the providers, we have got to learn how to start helping our providers. As I said earlier, there's a lot on their plate. There's a lot on everybody's plate, I do realize. They're at the center of what take care of the patient.

Shellie Sulzberger:

So start doing some lunch and learns. So ask the providers to bring their lunch or order pizza, and have your coding and billing staff pull out the most common errors they're finding. Find two or three that have not so great documentation, or common errors, and then find one or two really good documentation reports. Have your coders and billers work those up in advance, and then give the providers a copy that's not worked up, and then go through and say, "Okay, this is an established patient. I'm going to give you five minutes. If this were your patient, what level of service would you bill? What's documented really well? What's not documented really well? And is there anything in here that looks odd or discrepancies, or if you were doing a peer review on this, what would you say to this provider?"

Shellie Sulzberger:

Go around the room and have everybody answer it. Because a lot of times, if you just say, "Well, what would you bill?" Somebody says, "Level three." "Oh yup, that's right." And we move on. But go through and ask everybody, and it will cultivate your providers talking, "Oh, you'd bill level four? Why would you bill a four? I would have only billed a three." And gets them talking. And then your facilitator, either coding or billing staff can go through and say, "Okay, this actually supports whatever level. Here's why. Here's what type of history we have. Here's what type of exam we have, and here's what type of medical decision-making. Now doctors, look here, we've got diabetes but we don't know if it's type one or type two. We don't know if it's controlled or uncontrolled. We don't know if there's any other associated complications, or manifestations." And really go through the whole note in general, or you documented it for 14 review assistance for a runny nose. You only need one or two to bill for this level of service. And really go through and educate them based upon their own documentation.

Shellie Sulzberger:

Your coding and billing staff can also shadow the providers. Spend time with them, go in the room, stand in the corner, listen and observe what they are actually performing and doing with the patient. When they come out, talk to them about what level of service would they bill, based upon what just happened, and then tell them about what code it should actually be, based upon what happened, and how to document that. So there's different ways that you can do education. Do internal chart reviews, do external chart reviews, but spend time educating our providers. Our providers want to code a bill correctly. They just don't want all of the work. So we have to learn to teach them what do we need from a complete, concise patient safety, credible note, versus what we don't really need. So again, it's tying all of that together. We need it for coding and billing, and compliance, clinical et cetera.

Shellie Sulzberger:




Page 23 of 29

So then when you're thinking about the team, as I said earlier, it takes the entire team. We need a whole group of skilled individuals. We all have to be driven by a common goal, and we all have to agree on the game plan. So it's going to take your providers, it's going to take your other staff, your clinical team, your administrative team, your C-suite, your coding and billing team. It's going to take everybody. We have to work together often enough. We have to know each other's strengths as well as each other's weakness. We need to regularly meet and discuss our game plan, and talk about things to improve on to achieve our overall goal. And then of course, ideally, we want to have an experience captain, if you will, or coach, that's going to go through and make suggestions, and really help us outline a game plan for the team to move forward. And then we need to reassess that.

Shellie Sulzberger:

So when we're looking at our team, we have to identify what problems we have, because as I said earlier, we need completed accurate recordings to give us meaningful data between providers as well as payers. We need prevention strategies. So take extra time to huddle. If you're about huddling, learn how to huddle and meet with your team, review the charts and advance, and start really evaluating what that patient's being seen for, what the provider's d

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Transcript of This transcript was exported on Apr 02, 2020 - view latest ......Page 2 of 29 that they're coding...