Training Prep: Step-by-Step
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.
- Be sure to define the difference in medical necessity and clinical decision for medical intervention. Inform the providers that complexity of care as demonstrated by the medical necessity is based completely on the documentation of each patient encounter.
- Use the medical necessity tool found on the reverse side of the comparison chart to identify how to use medical necessity to select the appropriate level of service.
- Integration of current sample charts (HIPAA compliant) should be used as a hands-on session to practice what is learned.
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, 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 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:
- The level of service the provider selected
- The level of service supported by the volume of documentation ONLY
- The level of service supported by the medical necessity ONLY
- The overall level of service that should have been billed to the carrier
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.
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.
- Of the records review, pull 2-3 samples and be sure include examples of both incorrect and correct leveling of the E&M service.
- Handwrite on these HIPAA compliant records direct feedback by encouraging additional elaboration with key points and noting streamlining in areas in which over documentation of the required components were noted.
- Be clear and confident in your findings and keep reminding the provider that the patient should look as sick or as stable as they appeared at the time of the encounter.
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. Using a HIPAA compliant office-based encounter, audit one of the notes using the 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.
|Broad Overview of E/M Changes|
|Defining the Differences in 2020 vs. 2021|
|Medical Necessity & E/M Changes|
|History & Exam in 2021: The Quandary|
|Understanding MDM in 2021: Part 1|
|Understanding MDM in 2021: Part 2|
|Understanding MDM in 2021: Part 3|
|Training Your Providers for 2021|
|Hands On 2020 vs. 2021|
|Hands On/ Q&A|