In this episode, Cyndy Kowalski, a manager in our Compliance Services Team at BESLER Consulting, discusses how to fix common physician documentation mistakes.
Michael Passanante: Hi, this is Mike Passanante. I am glad to be back with you today on the Hospital Finance Podcast. Today, I’m joined by Cyndy Kowalski who is a manager in our Compliance Services Team here at Besler Consulting . Welcome, Cyndy.
Cyndy Kowalski: Thank you, Mike. It’s good to be back here again.
Michael: In a previous podcast, Cyndy walked us through some of the essential elements associated with physician documentation and coding as well as some common mistakes. And today, Cyndy is going to talk to us about fixing some of the common errors and mistakes associated with physician documentation.
Cyndy, let me turn to you. If fixing all of these things, all of these mistakes (it seems pretty daunting), in your experience, can this be accomplished?
Cyndy: This can definitely be accomplished. I do not think that it is an easy task. I think it’s important as you develop your whole program around provider services documentation coding to really go back to the very basics and look at the very beginning, make sure that you have all of the right people who are involved.
This is not just a physician issue, a provider issue. It is an issue that crosses over many departments – patient financial services, reimbursement, billing, it could be case management, clinical documentation. So, you want to make sure that you have the right people, if you will, around the table.
And I think as we talk about fixing the mistakes, I think it’s important to go back and do an evaluation as to what you have currently in place. How did you get to the point where you are right now?
An example would be “Do you have processes in place for capturing all of this information? Do you use an electronic method or is it a hybrid? Do you do some manual documentation, some electronic documentation?”
“Who does the documentation? Is it the providers themselves going in into the record and doing their own documentation? Do you utilize scribes to capture that documentation? And what processes do you have in place around that?”
I think it’s important to remember the goal when it comes to physician documentation, accurate coding and certainly the reimbursement is to really put the time and effort in up front – policies and procedures, establishing a baseline. If you’re acquiring a new physician practice, have you performed your due diligence? Have you done a coding audit to establish where are the providers as they are coming in to the organization?
And then what systems do you have in place for future monitoring? Do you do a random sample? Do you perform audits every so many weeks, every so many months?
I also think it’s important to look at the timing when you do your audits, when you do your follow-up and education. You certainly don’t want to identify a problem or a concern and wait three months until you can get everybody back in the room so that you can talk about it. You really lose a lot of valuable corrective action time, if you will.
And I think the other component is the follow-up and the follow-through. It’s not a matter of fixing it right here and everybody moves on and forgets that it ever occurred. I think it’s important that everybody comes back in periodically to re-evaluate, to make sure you’re maintaining that level that you wish to be in.
Michael: Let’s talk about corrective action plans. What should a corrective action plan look like and who should be involved on those?
Cyndy: A corrective action is developed following an organization’s identification of the need for an improvement, a process improvement. In this case, related to physician documentation and coding, it may be a baseline audit or may be routine audits where there are concerns about the documentation, the coding.
The corrective action plan, again, when you think about who would be involved, you want to have the right people. Obviously, you’d want to have the providers, who are actually performing the service. As I mentioned, if there are scribes involved, we want to make sure that they’re included.
Anyone that is involved in the process that was identified as requiring improvement should be part of the corrective action plan. They should be aware of what the findings were. They should invest in those initiatives to improve and they should be included in the education and training as well as the re-monitoring or re-auditing.
Michael: You’ve touched on education. That’s come up before in our discussions. It sounds pretty basic, but I have the sense that it’s not. Can you expand on that and tell us a little bit more about education related to compliance.
Cyndy: Certainly! In a previous pod, I think one of the items I gave as a takeaway was educate, educate, educate. And I think that it is imperative for organizations everywhere to continuously provide the education and training. I don’t think it is beneficial to assume it’s a one-and-done and no additional education and/or training is necessary.
I think that it is important to establish what you want to educate on (not necessarily just for the sake of educating). Establish what the objectives are, what the goals are.
If you’re educating providers based on documentation and coding, you’d want to be sure that you’re including whatever best practices, any evidence based information that you can provide. And again, it’s a team effort, it’s a matter of working side-by-side with the providers to establish that win-win as far as sending out clean claims adjudicating them and certainly getting your reimbursement.
That’s really where I really think education and training are important.
Michael: Walk us through how you actually go about educating physicians.
Cyndy: Educating physicians, I think educating any adult, it’s important to remember that they are adult learners. They are not into the memorization and things like that. With physicians, I think it’s important as we develop education programs is to understand what their needs are.
Generally, physicians or providers will tell you that time is of the essence. It is often not easy to educate physicians. You want to determine based on the group that you’re working with how best to educate.
Do you educate them in a group perhaps at a department meeting? Do you do one-to-one training? And I think when you’re making those decisions with educating physicians, it’s important that the takeaway would be you want to stick with specialties.
It’s very challenging for the educator to educate a group of physicians at a medical staff meeting where there may be a hundred physicians in the room and you’re trying to provide – again, in this example of physician documentation and coding -to a variety of specialties. The orthopedic physicians are going to have different needs and questions than the cardiologists or the nephrologists.
So, I think that’s important. You want to make sure that whatever it is you’re providing as far as education, that it’s meaningful, that it is time-limited. A physician is only going to be able to give a certain amount of time given what they have to do each day.
I think it’s a balance to determine. Many physicians will say, “Stop me in the halls, stop me in the elevator, give me the elevator speech for ten seconds and I’m good to go.” I think there’s a balance. If you really want to perform comprehensive education that’s meaningful, it’s probably a 45-minute to an hour session.
In addition, to make it beneficial to the physician, use the opportunity to perhaps use their own records, performing an audit on individual physicians in one specialty and being able to sit with them perhaps one to one and review those records.
Identify those areas where you found the documentation to be good versus areas where you would suggest improvements and then make those suggestions rather than say, “You did this well, you didn’t do this well.” Offer some information to show them what exactly what you mean. Give an example.
We know that a lot of physicians will tell us that prefer web-based training and education. And that is definitely beneficial. One thing that we’re learning is if you’re educating based on the results of an audit for the initial education and training, we’ve found that it’s been received a little differently if we’re able to sit one-on-one with those records as opposed to doing a web-based general education.
Certainly, for continuing education and general physician coding education, I think web-based would be fantastic. Physicians can access it when they have the time. I think there is a place for that specifically relating to educating as a result of an audit. The initial would be best served doing face-to-face.
There’s also an opportunity at times where a peer-to-peer education session may be more beneficial than the clinical documentation team providing the education or a case manager or a clinical nurse where a physician to a physician may be warranted for a variety of reasons. I think they’ve all worked well and it depends on the situation.
I think that’s probably the takeaway. It’s making sure that whatever it is that you’re planning as far as the education, it is specific to your audience and based on whatever your objective is.
Michael: And variety and creativity definitely have to play a part at this plan, right?
Cyndy: Absolutely. Same-old, same-old doesn’t necessarily seem to work. Again, you want to make it as unique as possible. You want to understand, again, even prior to the session, maybe with the department chair to understand with all of the data and the results of these audits what it is telling you?
Is it telling you that you need to look at medical necessity? Is it telling you that there’s documentation related to review of systems and examinations? Perhaps that you’re noticing the trend with the utilization of scribes?
So, it’s important to focus in on exactly what it is you’re trying to improve on, what process and then building on that. I think it’s important, as we discussed, to determine how best your providers are going to learn. If there are results that are not as positive as you expect, that may just automatically warrant a one-to-one where you can literally just go through those records and really do a focused education, if you will, as opposed to bringing in a small group of five, six, seven providers and educating on a whole.
Michael: Following a round of focused education, what are some of the next steps and how should they work?
Cyndy: Following the education, one of the first steps would be to provide that opportunity to have that information sink in. Following the education program, you want to be sure that the physicians have time to digest the information. Generally, within a day or two, we may bump in to physicians who will say, “Based on what you said, I have a question. I have this.”
You want to make sure that there are people available for that further discussion, whether it’s at the end of the discussion or a day later or two days later. I think that’s important, that it’s not, as I’ve mentioned before, one–and-done and they never see anyone again.
I think after that, you want to start making the determination what type of monitoring you’re going to do moving forward and certainly whether someone is monitoring the records, maybe it’s an office manager, maybe it’s a billing person, maybe it’s a clinical documentation team, where they’re just monitoring to see if there is any noticeable improvements, any challenges, things like that, which is a little bit different than actually performing an audit.
You may do a random selection of records, you may decide to bring in an outside person or someone else outside of the department where it’s more of an objective review, if you will.
There are a few steps. I think what’s important is after the education, the monitoring, and the re-audit, everyone comes back again, talks about the corrective action, what has been accomplished, where some of the successes have been, but also where some of the challenges continue. And based on that, you may find that re-education is necessary.
I think that’s important, again, to do in a timely basis. You don’t want to do all of this over the course of a year. You would really want to focus in on, “We have these results. We’re going to educate, re-audit, re-monitor within three months. Everyone’s been educated, so we want to do this” and then come back around.
Just like anything else, if you put it away on a shelf and then want to revisit it in six months or a year, you’ve lost that momentum, if you will, to make sure you’re making those improvements.
Michael: Cyndy, corrective action plans, they’re both multi-faceted and fluid. If you’re going through this, how do you determine that your plan is working?
Cyndy: The first way that you would identify if this corrective action is working is if your claims are being adjudicated. Are you seeing a decrease in your denials? Are you not getting returns to re-submit claims?
I think part of corrective action would be to understand what your baseline is already. If you know x number of physicians have a significantly higher denial rate than other physicians, you certainly would want to know that going in. And then as you implement your corrective action, you want to keep bench marking against that. Are you able to demonstrate improvement?
And again, you want to collect the data. You want to keep doing the audits, you want to do the monitoring. But you want to be sure that you’re documenting so that over time, you can actually show a picture. If you were at this percent, 70% compliant with the coding audit when you first started, obviously you’d like to see that trend going up.
And maybe you do see the trend is going up. And then based on operational issues, perhaps you’re going through a computer conversion, all of a sudden, you see everybody’s dipping back down into 50% and 60%.
It would be nice to be to be able to say, “Okay, look, we’ve been tracking, trending, if you will, in a positive direction and right around the time of our conversion, here’s what we’ve been able to identify.”
And that may be helpful that you’re able to say on this date at this time, “Here’s what was going on,” and then make those corrections, add that in as a bit of a learning curve. Make that note, but then be able to say, “Okay, we have everybody up and going on the electronic record and now we’re going to re-audit.”
It’s a matter of establishing your baseline data and then continuously comparing it, benchmarking it, and improving it.
And when you get to 100%, you just find something else to monitor because there are just always areas through your data collection and analyzing that you’ll find for process improvement.
Michael: Last thing, what is your final piece of advice for our audience when it comes to fixing physician documentation errors?
Cyndy: I think my final message would be summarizing what we’ve talked about, establishing your framework, your bench mark, understanding what processes you have in place, being sure that you’re following your processes, your policies and procedures.
If as a result of an audit, whether you’re bench marking or you’re doing continuous auditing, if there’s a plan of correction, it’s monitoring it, sticking to it, performing it in a timely manner, making sure you’re involving all the key people, you’re doing your education and your training, and then you continue with the monitoring and the auditing.
There is nothing static about compliance. It is fluid. Things change on a daily basis sometimes. You want to be sure you stay on top of all of those things and that as you discover them, you’re sharing that information and you’re making those modifications so that you can maintain the compliant process.
Michael: Great information, Cyndy. And thanks again for coming by and spending some time with us today.
Cyndy: Thanks, Mike.