Across all specialties, we often find documentation deficiencies in the various source documents. For example, Oral physicians were trained in prestigious schools, leaving with complete understanding of how to properly document in book format; however, as soon as they become full-time providers, they start to document with text message language. Abbreviations and the absolute shortest explanations are commonly used for documentation, which in and of itself does not follow any regulations. Unfortunately, this then translates to very little documentation on why their patient needs the treatment and how follow-up is going to be put into place to help prevent more issues for the patient.
Treatments provided all have a “why” attached to the procedure. What if a patient you are treating needs a root canal and the patient did not have the root canal performed? Ask the patient why. Document this reason in full! There could be several reasons they did not have treatment and their file needs to have the complete reason why. Perhaps ones of the reasons the patient did not receive treatment was due to lack of a complete understanding and after the procedure was explained, the patient would want to receive treatment.
One of the biggest problems we as healthcare providers face today are lawsuits. These are common due to neglect of information and education. Simple fixes. Easily avoidable. Why not avoid one by just taking the time to slow down and assess the file in full and notate in full? We feel that the first step in eliminating this problem is training the providers and their teams on proper record documentation.
Our goal is not to turn the doctors into coders, but to give them the information and tools they need use every day to wholly and accurately report their services. Over-and-over we see that the most significant documentation and compliance problems arise from what the physicians and team do not know. This training will improve the quality of patients’ medical records and will give the coders –be they the physicians themselves or the practice’s staff, or outside third- party companies much-improved chance to optimize the revenue potential of each-and-every patient-care service provided by the physicians.
All of our training programs are specialty-specific, so we suggest they be held as single specialty presentations. Training assures the physicians in the audience that everything will be pertinent to them. There is no limit to the number of physicians and staff who can attend our documentation training presentations.
Our training sessions generally cover a substantial amount of material, so, if desired, we will work with the practice’s leadership to customize the training presentation specifically to the client’s needs. If a coding audit is completed before the training sessions, those findings will be integrated into the program to make it even more meaningful to the individual providers. The full program and questions-and-answers can take 4-6 hours to deliver and includes, among other topics:
- An Overview of the Evaluation & Management system
- The components needed for documentation on every office visit
- History of Present Illness
- Chief Complaint
- Review of Systems
- Past Family & Social History
- Clinical Examination
- Decision Making
- Coordination of Care
- Nature of the Presenting Problem
- Informed/Refusal forms
- Each team will be able to write a letter of medical necessity by the time all of the needed information is entered into the system and will not need to go to the providers asking for more details.
- A set up of a SOAP form with the questions each person on the team will need to fill out to work with the provider with complete documentation.
- Documentation Requirements for each type of service provided within your office
- Consult codes are not payable for Medicare providers and a lot of others will follow suite
- Observation Services and Documentation Requirements
- Concurrent Care and Documentation Requirements
- Suggested Contents of an Operative Report
- Modifiers and the documentation they require, including, among others:
- Increased Procedural Services (22)
- Bilateral (50) –vs.- LT and RT
- E&M services and treatment on the same day by the same doctor
- Emergency Visits
- Medicare Regulations
- ABN requirements