This step is recommended for implementation February 2020
Most providers have only been taught documentation requirements since residency. The best way to approach this change is to first conduct training identifying this requirement by Medicare in the Claims Processing Manual.

Shadowing is an extension of the hands-on application of Step One. This step should begin within 9-12 weeks of the completion of Step One. Completion should be approximately April 30, 2020, but may vary based on the size and difficulty of scheduling within your organization.

While most providers are not as receptive to shadowing during clinic, this exercise can be quite effective in another hands-on learning technique. Discussing the encounter, the complexities or the lack thereof and identifying the best approach to documentation content by focusing not on maxing out the requirements, but rather purposeful documentation to demonstrate complexity to support the most appropriate medical necessity.

Review of documentation vs. coding. Upon maintaining the above pace for training, this step should begin around May 2020 and should be conducted over the next 4 months. Again, this may vary on sample size and organization size.

Now it is time to evaluate the return on the training investment from Steps One and Two. Review 5, 10, or 15 records per provider. The sample size should be encompassing enough, but keep in mind this is validation of education and not meant to take the place of your annual compliance review for. It may be prudent to show 4 main findings of each encounter for this review:

Including each one of these will provide a basis for educating in proficiencies and deficiencies on selecting the level of service. Of note, if your organization has been requiring MDM as the key indicator for the level of service, we would recommend having it as a main finding as well to educate on this difference.

Feedback
No review (ie., audit) is complete without feedback and education on any noted changes, why the changes were needed, and efficient strategies to implement for documentation improvement while maintaining patient care as the focus of each encounter. 65% of the population are visual learners and by nature many providers are analytical thinkers. Therefore, a combination of the two should lead to an effective educational approach.

Continue the review cycle and integrate 2021 changes.
Every 6-8 weeks continue to provide spot reviews on the providers who need additional training for better compliance. During each 6-8 week begin the push toward 2021 prep. Using a HIPAA compliant office-based encounter, audit one of the notes using the current 2020 documentation requirements and medical necessity guidelines. Now, take the same encounter and using 2021 rules audit the same note for a cross comparison of the new guidelines.