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