Reader Question: Getting Physicians on Board

Question: Physicians already believe they have too much paperwork to do. How can I convince my doctors to help me adjust to APCs, because I now need to use their documentation before I can process my bills?

Illinois Subscriber

Answer: One of the downfalls of todays coding system is its failure to provide feedback to the healthcare providers about how their records may or may not meet documentation requirements. That is not to say that physicians are not provided with educational workshops. But facilities should expend the resources to go that extra mile and provide them case-by-case feedback when their charts fall short in providing the needed documentation for coders to bill accurately.

Most physicians want to do a good job, but their coding education requires more than a two-hour documentation orientation session every 12 months to get the message across. One of the most effective methods of interaction with doctors regarding the documentation issue involves providing them downcoding reports on a routine basis (i.e., monthly).

For example, if you consider the level of medical decision-making the best way to determine what the evaluation and management level should be, then generate an exception report for each record in which the history and physical examination levels fall short of the medical decision-making level.

Of course, to set up a system this detailed, coders will require specialized training themselves. But the outcome in improved documentation and compliance, as well as optimization of revenues, offers an attractive benefit for such a program. By providing the physicians with immediate feedback on their own records, they can learn the ins and outs of documentation and coding requirements much faster and begin to provide more substantial documentation of services to allow coders to do their jobs more efficiently.


- Published on 2000-04-01