June 30, 2023 | By Sonal Patel, CPMA, CPC, CMC, ICDCM
One of my favorite childhood memories includes learning how to paint. Messy and fun, fingerpainting and potato printing held my attention for years. As I got a little older, I marveled at how I could create masterpieces by using the “paint by numbers” method. At the time, I considered myself talented (wink, wink). In hindsight, I recognize its very construct allowed me to express myself further and develop my own creative, painterly style in my pastels, acrylics, and oil paintings.
I believe this structured style can serve healthcare providers very well when it comes to their documentation practices in 2023 and beyond. Today, our doctors and practitioners are faced with increased payor scrutiny and regulatory constraints when it comes to these entities reviewing clinical documentation and finding it to be deficient. The past few years have seen major guideline changes, if not expansive overhauls in CPT®, when it comes to evaluation and management services (“E/M”) in the office, outpatient, and inpatient settings. Although the American Medical Association embraced the Centers for Medicare and Medicaid Services’ ‘Patients over Paperwork Initiative’ to help reduce the administrative burdens providers have long faced, this shift has nonetheless left practitioners vulnerable. In my opinion, with all this novelty comes an opportunity to impress upon our healthcare providers that recurring education is necessary for them to remain in coding compliance and mitigate the current risks they face.
My approach to providing education in the current landscape is multi-faceted due to the complexity and myriad of silos that remain in place in the various business departments from organization to organization. Nonetheless, for the purposes of this article, I will only focus on provider education. In my opinion, for something as massive as the recent E/M changes, I believe taking a piecemeal stance is appropriate so physicians have the chance to better incorporate what they have learned into their unique documentation style. Allowing transparency and open communication during the education session(s) is critical. I have spoken to numerous providers over the years and they have all provided detailed information and insights on the patient encounters I audited. Time and time again, those glorious nuggets were not captured in the documentation audited! Once they hear me applaud the critical thinking and medical decision-making process they so effortlessly provided, albeit verbally, their eyes inevitably light up; the light-bulb moment, the a-ha moment, whatever you want to call it, that moment is all it takes for change, for improvement to happen.
Our physicians and qualified healthcare professionals have had extensive years of medical school education and formidable training. They each possess expertise and passion for the art of healing, which they gained from generous experience and their years learning the science of medicine. As a medical coder, medical auditor, and medical compliance professional, I do not question or seek clarity in their area of mastery. Rather, the niche work I find myself performing over the years is within, what I call, the art of business medicine. The art of business medicine is comprised of two distinct concepts – the art of clinical documentation and the science of medical coding. With every claim they submit to commercial and government payors, physicians certify they have selected the appropriate code(s) for the service(s) rendered on a unique date of service to a specific patient. To put it plainly, there are just shy of 11,000 CPT® codes in 2023 that require congruence with medical documentation. Ensuring the fine details within each code are met requires the art of language, and the finesse of clinical documentation to better support the code selection. I believe I can serve as that bridge between the two concepts to help providers achieve (and remain in) coding compliance. To that end, I believe a “paint by numbers” method would better serve them to ensure all the elements of the patient’s medical picture are told. The elements of a compliant E/M encounter can be painted in some of my favorite shades of Crayola® blue:
- Aquamarine – medically appropriate history and physical examination
- Cornflower – number and complexity of problems addressed
- Cadet – amount and/or complexity of data analyzed
- Prussian blue – risk of complications of patient management and treatment
- Blue-green – diagnosis code(s) with complete specificity
Further still, compliant surgical encounters of the patient can be painted in some of my favorite shades of Crayola® green:
- Green – heading of operative report
- Olive – indications for surgery in operative report
- Forest green – body of operative report
- Sea green – findings in operative report
- Cerulean – diagnosis code(s) with complete specificity
This “paint by numbers” approach can be applied to capture all the other fine details in each category above as well. It can also be utilized for every specialty of medicine and painted in many other colors – from shades of red for anesthesiology to shades of orange for laboratory medicine to shades of purple for radiology and beyond. Each specialty is as rich as the next with complexity and variation in clinical documentation elements that must be captured to remain compliant. Of course, the overarching medical necessity for all services rendered can always be applied in any shade of fine metal to complement that significance, be it gold, rose gold, bronze, platinum, or silver. This step-by-step methodology can serve as a tool for both providers and business medicine professionals alike in securing coding compliance with payor policies and establishing appropriate reimbursement the first time.
Without a doubt, the vast majority of physicians and healthcare practitioners provide meaningful, significant care to multiple patient populations. Afterall, the patients they serve are unique individuals with individualized treatment plans and goals to remain stable. Still, the current electronic medical record systems do not allow for the critical thinking and nuanced medical decision-making that physicians possess. Gone are the days of organic writing, actual pen-on-paper days where our providers’ fluid thoughts were once held. So, I am of the mindset where I embrace the adage, “paint the medical picture”, and I strive to assist qualified healthcare professionals in creating masterpieces of clinical documentation to better support medical code selection. In this modern healthcare landscape, I believe the art of business medicine requires the efforts of both providers and business medicine professionals alike to achieve coding compliance.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips.
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend.
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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