With the advent of ongoing audits for medical necessity and accurate coding, whose documentation is being scrutinized to ensure that the medical services being provided are reasonable and necessary? The answer: physicians.
With the advent of ongoing audits for medical necessity and accurate coding, and an increase in denials by Recovery Auditors (RAs), Medicare Administrative Contractors (MACs), Commercial Payers, and others, proper documentation in the medical record has become more important than ever. And whose documentation is being scrutinized to ensure that the medical services being provided are reasonable and necessary? The answer: physicians.
For the last 17 years, the “1997 Documentation Guidelines for Evaluation and Management Services” has served as a benchmark for physician documentation. And yes, you read that correctly — there have not been any formal updates since 1997. When you think about it, RAs were not even around in 1997. The MACs were years away from forming, and commercial payers were not aggressively pursuing concurrent and retrograde audits to any degree.
Doctors typically document for other doctors. They do not document for coders, Utilization Management (UM) staff, or other reviewers. To put it into perspective, for every one physician that reads another physician’s History and Physical (H&P), there may be as many as 20 non-physicians who will read that same document.
Physician documentation has evolved over the years, but not always in a good way. There are a number of reasons why physician documentation has deteriorated, but the 2 primary factors for this are the emergence of the electronic health record (EHR) and the uneasy transition from a source-oriented record to a problem-oriented record.
Electronic Health Records — Friend or Foe?
In terms of physician documentation, the road to EHR adoption has been a bumpy one at best and has faced many challenges along the way:
Transitioning to a Problem-Oriented Record
In the late 1960s, one of medicine’s revolutionary thinkers, Lawrence Weed, MD, developed the problem-oriented medical record (and deservedly became known as the “Father of POMR” in the process). The POMR is a disciplined approach for physicians to provide proper documentation in the medical record. Through POMR, Weed created the SOAP note (an acronym for “Subjective, Objective, Assessment, Plan”), which gave physicians a structured approach to gathering and evaluating the volumes of information contained in the medical record and provided them with an avenue to better communicate with each other.
In his classic presentation to Emory Medical Center in 1971, Weed stated “…The way you handle data determines the way you think,” and “The structure of the data determines the quality of the output.” Think of it as a phrase we commonly use: “Garbage in, garbage out.” If the input data is not good, the output will be of the same quality. Physicians handle multiple elements of data from variable sources at variable times and then process that data in order to produce quality output translated into treatment plans. This is usually represented in the Assessment/Plan section of the H&P.
Today, physicians have essentially abandoned the fundamentals of the SOAP approach to the more straight-forward, but not necessarily well-rounded “Problem List” approach. For this transition to be effective, physicians must be able to successfully address the following:
As an example, the physician may note the following: peri-rectal abscess — presenting diagnosis with the following co-morbidities:
All of the problems are listed and the treatment of each of these problems may follow, but this process does not express the risk of potentially taking a patient who is anticoagulated to the OR, or a diabetic developing — or the risk of a diabetic developing – necrotizing fasciitis even while treatment is rendered. To a physician, these conclusions may be obvious (i.e., physicians document for other physicians). However, with this new audience of reviewers and coders are not allowed to draw conclusions unless stated by the physician.
The Power of the H&P
Arguably, the most important physician document in the medical record is the History and Physical. The H&P should be a stand-alone document, as it is the main evidence to support why the patient has come to the hospital and why they will be receiving the care provided. It is this explanation that provides the cornerstone of medical necessity for the level of care in which the services are provided. Going back to documentation basic principles, there are 11 elements that make up the H&P:
Thus far, I have reviewed 267 charts throughout the United States, randomly chosen by hospitals for documentation reviews. The reviews were performed, looking for deficiencies and areas for improvement to adequately document the acuity with which a patient presents. Below are the cumulative results from a total of 267 charts reviewed nationally:
# of Times Present
Xrays, EKG, Tests
What stands out in this data is the frequency in which essential elements of a patient’s H&P are missing. Remember what Dr. Weed said more than 40 years ago: “The structure of the data determines the quality of the output.” And the output in this situation is in the Assessment and Plan.
Following the Code
Another new audience affected by documentation is Clinical Documentation Improvement (CDI), which can have significant impact on physician’s quality measures. Oftentimes, physicians may misinterpret the use of coding for hospital revenue and not fully understand its importance of documentation for better accuracy and specificity.
Better documentation can affect 2 quality measures: Severity of Illness (SOI) and Risk of Mortality (ROM). These measurements are rated from 1 to 4 with the higher the number, the greater the acuity. In regards to this measurement, for the physicians who say, “But my patients are sicker,” better documentation will help physicians to get credit for that acuity. This is exactly some of the data that is being used to reflect the quality of physicians and comparing them to their peers. It can be found in many places, such as “HealthGrades.com” and Medicare’s “Physician Compare.”
There are many other audiences that physicians must document for other than their peers. Data is being collected based on this documentation, depicting the quality of physicians and comparing them to their peers. In the future, decisions for payment, employment, and patient satisfaction will play a very important role. We need to teach physicians to how to document for today’s standards, not those of 1997.
John D. Zelem, MD, FACS is Executive Medical Director, Client Relations & Education at Executive Health Resources, Newtown Square, PA.