When it comes to medical documentation, quality is more important than quantity. Overdocumentation, along with unnecessary or irrelevant information—sometimes called “note bloat”—can cloud what is important in a patient’s medical record. This can lead to wasted time; miscommunication between provider and patient; or worse, mistreatment of a patient’s conditions. Fighting note bloat will become even more important as the industry prepares for the Evaluation and Management (E/M) coding changes coming in January.
Documentation with a clear focus on quality provides a concise record that serves as an essential tool in facilitating the most appropriate care and ensures continuity of care. Outside of date of service, patient name, and provider name and signature, the key elements of medical documentation are as follows: reason for encounter, appropriate and relevant physical exam, review of pertinent tests, clinical impression, assessment, and plan of care. The patient’s record should reflect the provider’s thought processes and the complexity of medical decision-making as it relates to the patient’s condition(s).
Understanding Note Bloat
Causes for note bloat include the perception that data elements are required to attain a certain level of code and electronic health record (EHR) use. The 1995 and 1997 E/M Documentation Guidelines were intended to capture the complexity of the visit after the medically necessary service was performed and documented. However, some providers interpret the guidelines as a roadmap for achieving a certain level of service, and in turn, they document with that goal in mind, rather than determining the level of service as a secondary step.
Due to their own misinterpretation of the guidelines, and the development of EHRs based on the same, providers have long voiced concerns regarding the unnecessary administrative burden. Many providers express they spend more time trying to hit a specific number of data elements, rather than providing actual treatment of patient conditions.
Additionally, with the implementation of EHRs, some providers rely too heavily on the copy/paste feature—a huge compliance issue—to save time documenting visits. This method often leads to conflicting and/or inaccurate medical documentation. When a provider must read through a lengthy note that includes information irrelevant to the patient’s condition(s), important information can be overlooked. Copy/paste documentation can also be misleading to other providers participating in the patient’s care, causing them to pursue inappropriate treatment plans.
Coding Changes Focus on Medical Decision-Making
To combat note bloat, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) joined forces for the recently released changes to the current E/M Documentation Guidelines for the Office and Other Outpatient Visit code range (99202 – 99215). The new guidelines, scheduled to take effect January 1, 2021, focus on medical decision-making, and are intended to more closely reflect the actual work providers perform in treating patients’ conditions. The goal is that providers have more time to spend on patient care with less required for documentation or other administrative processes. The desired result is higher quality documentation leading to higher quality patient care.
Prepare Now for January 2021
As we prepare for the 2021 documentation changes, a good first step is to work on improving flexibility in provider documentation in the EHR, and focus on meaningful, medically necessary, and problem-pertinent documentation. Encourage documentation that helps a provider understand what he or she did at the prior visit, helps another provider who reads the note understand the same, and helps a judge or jury understand in the event of a malpractice suit. Once documentation is pared down to the important elements, train providers on the 2021 E/M Documentation Guidelines so they are prepared come January to properly select codes based on their documentation.
How PYA Can Help
PYA has assisted clients through complex coding and documentation transitions, including the rollout of International Classification of Diseases – 10th Revision (ICD-10) and the implementation of EHRs. We understand the intersection of coding and documentation requirements, EHR functionality, and operational workflow. If you need assistance with 2021 E/M Documentation Guideline training and gap analyses to identify documentation improvement areas, contact a PYA executive below at (800) 270-9629.
Read more about changes to 2021 guidelines in this recently published Report on Medicare Compliance, in which PYA’s Valerie Rock was quoted.