August 14, 2018

Is it Patients over Paperwork, or Providers over Patients?

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The author comments on proposed E&M changes.

Has my entire career been based on a lie? For 33 years, I have been espousing the party line that good documentation positively impacts patient care. I have taught documentation to providers who have gotten in trouble with their medical boards for six years, including appropriate evaluation and management (E&M) levels of service.

As I see it, the problem is not that following guidelines is excessively burdensome; it is that the guidelines were designed to stratify reimbursement, not to ensure excellent patient care.

The new proposed rule encompassing revisions to payment policies under the Medicare Physician Fee Schedule (https://www.regulations.gov/document?D=CMS-2018-0076-0621) suggests that the provider, in regard to outpatient office visits, should:

  • Continue to select a level of service (LOS) from 2-5
  • Need only document at a level 2
  • Get paid a single rate that is slightly higher than a current level 3 for any visit from LOS 2-5

The Centers for Medicare & Medicaid Services (CMS) wanting to reduce provider burden is commendable, but their solution seems ludicrous to me. Patients over paperwork, fine, but I say patients over providers, too. Excellent clinicians do excellent histories and physicals and document them along with their thought processes for a care plan because they feel the information they obtain is valuable, and what they are thinking contributes to the patient’s care, not because the government is making them. Documentation is not just a burden; it is an integral part of taking care of a patient.

Providers feel that documenting and re-documenting ridiculous elements that do not advance patient care is a waste of their precious time. This is accurate. Kudos to CMS for the relatively recent change in the way we handle medical student documentation. It was absurd to make a provider redo the entire documentation. My first suggestion: allow providers to utilize others’ documentation (medical assistants’, nurses’, NP/PAs’) without having to reiterate it. Review and concur or modify; then sign off and utilize it to take care of the patient.

It is dangerous for the clinician to not obtain their own history, solely relying on some ancillary personnel. Has no one else out there ever had the experience of the patient changing their story and telling them something important that contributes to taking excellent care of said patient? This IS why they pay you the big bucks. However, there is no utility in making the provider reenter the entire narrative again in the medical record. Bonus: this will also reduce note bloat. Consider the following:

I agree with the history as documented by my staff, except the patient stated to me that she was nauseated for two days before she started vomiting yesterday. She has not noted blood.

Want to eliminate obtaining worthless information just for billing purposes? I support that. Suggestion No. 2: CMS, stop mandating arbitrary family history and random review of systems.

Do you have to examine eight or more body systems for a level 4 or 5? It depends. Is there value to examining each body system? Does it help guide you to the diagnosis?

That is the crux of the matter to me. Is there value in obtaining that historical point or examining that body part? Is the data you derive from that lab or X-ray value added?

I think we should be compensated for managing sick and complex patients commensurate with the amount of effort and time it took to make sound medical decisions. Here’s what I would propose:

  1. Make new 2018 guidelines.
    1. History must provide details of the chief complaint. History may be obtained by ancillary personnel, but must be reviewed and validated by the provider. For established patients, it may refer to previous encounter(s) and give interval history details. Stop incentivizing copying and pasting of previous documentation in prior notes. Have the provider tell the story!
    2. Pertinent past medical/surgical history and family history should be obtained.
    3. Pertinent social history should be obtained. This may include tobacco, alcohol, or substance use or family/social situation. There is almost always some relevant social history.
    4. Review of systems should be obtained, as appropriate. There should be no numerical value of systems mandated. Its purpose is to ensure that there does not exist a more serious problem that the patient doesn’t recognize.
    5. The physical examination should be appropriate for the chief complaints/chronic conditions/potential diagnoses.
    6. Medical decision-making should clearly lay out what the provider was considering and thinking, what the plan to evaluate the problems was, and what the investigative studies demonstrated and what they mean.
    7. All diagnoses relevant and/or addressed on this encounter should be listed.
  2. As is current practice, medical necessity must be met for every encounter.
  3. Submission of a bill for payment should be based on:
    1. Complexity of medical decision-making (MDM)
      1. Acute or severe problems
      2. Multiple problems being simultaneously managed
      3. High risk to patient or provider

        OR

    2. Time
      1. Complex history acquisition (e.g., due to challenging historian, obtaining from others, language barrier, dementia, etc.)
      2. Review of multiple diagnostic studies
      3. Complex counseling, explanation of studies, discussion of treatment options, emotional concerns. Spending extra time to talk a patient out of an unnecessary antibiotic or discovering suicidality is worth it and should be compensated
      4. Consultation and discussion with other providers
      5. Eliminate requirement for “greater than 50 percent of time spent in counseling or coordination of care”
    3. Eliminate the combination of history and physical as sole determinants of LOS. Any patient can be documented at the highest level of history and physical, as currently set out in the 1995/1997 guidelines. If there is no medical necessity to examine the body part, you shouldn’t be able to use it to justify a higher level of service. The bar will now be to do the PE that is appropriate to the chief complaint, and this should always be met. Documentation of the history and physical is for advancing patient care, not for justification of reimbursement.

Pay the providers the appropriate amount for the work product they produced. A blended rate will clearly penalize providers who see the sickest and most complex patients, who also take the longest time to sort out. “Budget-neutral” is for the system, not for a given individual provider. Would you eagerly sign up to get paid $135 for a patient for whom you used to get paid $211? Providers will opt out of Medicare in droves, and patients will end up paying the price.

You should need fewer auditors. LOS 2 is a minor or trival problem, LOS 5 is truly sick or complex; LOS 3 and 4 are everyone else. Tie goes to the runner. Forget that HCPCS G-code add-on! Have auditors go find real fraud and abuse. We doctors don’t want those folks in our club, either.

CMS created the burden by making documentation about billing and not about taking care of the patient. Don’t lower the bar for documentation. Re-associate documentation with patient care and pay providers for taking excellent care of patients. The best business model is the best patient care. Patients over everything.

CMS is accepting comments on the proposed rule regarding the Physician Fee Schedule until 11:59 p.m. on Sept. 10. Let them know what you think!

https://www.regulations.gov/document?D=CMS-2018-0076-0621

Program Note:

Listen to Dr. Remer every Tuesday on Talk Ten Tuesday, 10 a.m. ET.

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Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk-Ten-Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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