July 9, 2021 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
After 6 months of speaking to the 2021 AMA guidelines, many of you may be tired of talking about the new documentation guidelines. But the other half of us are frustrated at still seeing documentation come through that represents the mandated constraints of the old guidelines. With these providers and organizations choosing to roll with, as opposed to changing and adapting, their complacency has continued to yield documentation that is less about the patient encounter, and more about completing a task list and potentially jeopardizing patient care.
In my 25 plus years of healthcare, I have heard providers asking for “patients over paperwork”. We now have those relaxations in place, but the documentation that we are still seeing is more reflective of “paperwork over patient”. Why? Why have changes not been made? While the answers could be wide-ranging depending on your organization, I want to address 3 possible reasons: 1) Templates; 2) Lack of understanding; and 3) Budgets.
With EMR integrations within practices across the country, much effort, countless hours, and thousands of dollars were spent on implementation to include creating, tweaking, and managing templates (and sometimes overpopulated templates). It then makes sense that providers and organizations wouldn’t just wake up on January 1, 2021 and blindly delete these templates after such an investment; especially without first waiting to see if these changes were really going to stay. Additionally, we could add that in theory, it is much easier to start a note with a template; a copy, paste, pull-forward as opposed to a plain white sheet staring back at you, or even to start building new templates. This easier concept is what “sold” us on full adaptation into EMR when so many of us fully resisted integration after all. But patients over paperwork means we put the patient back in the note so the documentation actually answers the “who, what, when, why, and how” of the encounter.
Lack of Understanding:
Most practices I have encountered in 2021 gave some form of education to their providers regarding the 2021 E&M changes. What I am not sure we can attest to is the level of understanding the providers achieved- and for just a moment- I’m NOT talking about their mastery of assigning the level of service. Instead, I’m referring to their ability to understand the theoretical differences between the concepts 95/97 and 2021. What I mean here are the documentation liberties given to the provider through 2021 changes. This has become apparent as I have read notes over and over that could be documented more effectively and efficiently, in a way that communicates the patient-provider interaction much better, then moved to the education session with the provider to hear their pent-up frustration at archaic documentation requirements that prevent them from delivering the best patient care.
When I begin to explain that the guidelines have changed and they do have more autonomy in the style of their documentation today, sometimes they respond as if they haven’t received 2021 education at all -when we in fact know they did. My point is that it is halfway through the year and maybe it is time for a refresher course. During this refresher course, instead of teaching the guidelines, maybe a comparative analysis would offer a fresh approach.
In so many ways, it seems that most things always come back around to money, and in many ways, I don’t think we are without exception here. Change is never easy because change requires training, implementation, and quality control; all of these take an increase in budgets, which we’ve already spent when we added EMRs in our practice. Many practices have kept going with their tried-and-true templates because they have “passed the audit test” and if they change them or start free-texting notes under the new 2021 documentation guidelines, audits will be needed. Based on many practice revenues from 2020, overall budgets have been tightened and many have eliminated compliance audit budgets completely. Not exactly the best compliance approach, especially in a year with the first documentation guideline changes in 25 years. Instead, make the changes, but scale down your audit sample. Review 5 encounters per provider instead of reviewing 10 or 20 encounters per provider (which makes sense because there is no longer a coding variation between new or established patients). If your budgets still cannot withstand this scale of a project, then just audit 5-10 encounters for the entire practice and review them together in a group setting with the auditor noting the deficiencies and proficiencies of each to create solid and sustainable documentation.
Our providers have been given what they have asked for – relaxed documentation guidelines… patients over paperwork… the SOAP note reinvented. Let’s help them figure out how to implement it into their day-to-day workflows.