Improving physician documentation has never been more important than in today’s era of a looming compliance deadline for using ICD-10 code sets and continued reductions in insurance reimbursement coupled with more out-of-pocket costs for patients, not to mention improved safety and quality of care.
But too many physician practices are behind in efforts to improve documentation, says Deborah Robb, director of physician services at TrustHCS, a Springfield, Mo.-based coding and revenue cycle consultancy. “You’d be surprised how many don’t assess the documentation skills of new physicians.” And they often don’t focus on the skills of current physicians either.
At the MGMA 2013 Annual Conference, Oct. 6-9 in San Diego, Robb and colleague Lori Owens, director of physician coding operations, will discuss creating a physician documentation training manual, an on-boarding program for new physicians and a framework for auditing documentation at education session F10, “Getting it Right: How to Improve Physician Documentation in Practice.”
A training manual specific to a physician’s specialty can go far behind basic tutoring by also being a one-place repository for related information, Robb says. “No one remembers all the protocols and policies, so a manual is a nice thing to have.”
The main problem with documentation training and improvement programs, Robb contends, is that there often is little follow-up. She suggests, for physicians and coders, starting ICD-10 training now. When ready to code, have them begin by coding one chart a week to see where they need more education. As they improve, audit performance after 90 days, and then six months later to see if bad habits have reappeared. Remember, Robb cautions, physicians are more receptive to ICD-10 today than they previously were, but are frustrated as many also are still learning to use electronic health records. “Always find a positive when you’re doing any form of auditing of a provider. Always identify their strong points, and then work on the weak points.”
Now also is the time to find physician and coder champions for ICD-10 who can help colleagues. While small practices might wait until three months before the October 2014 deadline to kick ICD-10 training into high gear, larger practices and hospitals should consider starting now.
The education session is scheduled at 9:45 a.m. on October 8.
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