Measure Your HIPAA Data Compliance Against This Checklist

Find out whether you’re doing all you must to avoid costly violations.

You’ve probably noticed plenty of websites asking you to accept “cookies” or rejoin email lists this summer. That’s because the EU’s General Data Protection Regulation (GDPR) took effect May 25. Designed to give European citizens more say over how their personal information is collected and used, the GDPR ranks among the world’s strongest data privacy laws.

Because the GDPR applies to companies doing business with Europeans wherever those companies are based, it will inevitably affect U.S. healthcare organizations. American providers already need to exercise greater caution with patient information to achieve HIPAA data compliance, but the GDPR holds the industry to even stricter standards.

For instance, under the GDPR:

• Patients must give active and express consent for organizations, including healthcare organizations, to collect and store their personal details. (Under HIPAA, organizations don’t need consent, but must store personal details securely.)
• Patients have the right to erasure (the “right to be forgotten”). (Under HIPAA, as Health IT Outcomes explains, “any patient record that is in the hospital’s database cannot be erased simply because the patient wants to.”)
• Organizations must notify patients of any data breach within 72 hours of becoming aware of it. (Under HIPAA, organizations have up to 60 days.)

And GDPR fines for non-compliance can be more severe than HIPAA fines. Where violations of the U.S. law can cost, at the most, $50,000 each with an annual maximum of $1.5 million, failures to comply with GDPR can run a maximum of 20 million euros (about $23 million), or up to 4% of the preceding fiscal year’s total global turnover, whichever is higher.

The GDPR is “widely considered to be the next-generation model for privacy protections,” Tony Abraham writes for Healthcare Dive. It shines a bright light on people’s rights to information security. That focus, together with the American healthcare industry’s continuing vulnerability to data breaches—more than one is reported every day, according to HIPAA Journal—leads some observers to wonder whether the U.S. should adopt stricter standards for handling patients’ protected health information (PHI).

A Six-Point HIPAA Data Compliance Checklist for Your Organization

We’re not legislators at MDCodePro and can’t predict what U.S. lawmakers will do. We urge providers to aim for the greatest possible compliance with all current legislation.

Though our focus is compliance with CMS documentation guidelines, we’ve put together a simple, six-point checklist you can use to strengthen your e-compliance with HIPAA. It’s no substitute for professional legal counsel or information technology advice, but it may help identify your organization’s most pressing compliance goals, as well as steps you must take to reach them.

Answer “true” or “false” to each of these statements:

1. We have assessed our data security risk and taken appropriate action.

HIPAA requires your organization to assess the risks facing its PHI and reduce them to the lowest level reasonably possible. A thorough analysis of threats and vulnerabilities will flag potential problems involving the confidentiality, integrity, and availability of all protected information, including e-PHI (PHI in electronic form), your organization creates, maintains, transmits, or receives before these problems occur.

This assessment is more than a task you must complete to be compliant. It’s a way to honor the trust your patients give you as their healthcare provider. The Office of the National Coordinator for Health Information Technology (ONC) offers a downloadable risk assessment tool to help you document your organization’s risks and take steps to address them.

2. We are encrypting all patient information.

Strictly speaking, HIPAA doesn’t make data encryption a “required” measure. It’s an “addressable” one. But this distinction only means organizations may document an “equivalent alternative” producing the same result if, based on risk analysis, encryption isn’t “reasonable and appropriate.” When you contemplate the damage done to your patients’ privacy and your reputation should unencrypted e-PHI be breached, it’s tough to conclude encryption is anything but “very necessary,” as HealthITSecurity states.

Even when you keep decryption keys separate from encrypted data (as the law requires you must), encryption isn’t foolproof and must be used with other safeguards for maximum effectiveness. But since the healthcare sector sees more devices storing unencrypted data stolen than others and double the cyberattacks, encryption is a vital investment in HIPAA data compliance and your own peace of mind—and one today’s technology makes easier than ever.

3. We have policies about using e-PHI with mobile devices.

While mobile device adoption is on the rise in healthcare, increased reliance on tablets, smartphones, laptops and portable drives brings an increased risk of e-PHI ending up where it shouldn’t. In 2015-2017, breaches involving mobile devices exposed 1,303,760 patients and plan member records, reports HIPAA Journal.

Your policies should recognize how important mobile technology can be when caring for patients and communicating with them and with staff, but also regulate how employees use those devices to access, view, and transmit e-PHI. HHS’ Office for Civil Rights (OCR) recommends safeguards like user authentication, automatic lock/logoff and remote wipe capabilities, secure Wi-Fi and VPNs (Virtual Private Networks), and data encryption.

4. We are centralizing data storage and reviewing data access.

HIPAA doesn’t dictate whether you use a physical server or store e-PHI in the cloud. The cloud may prove, as Health IT Outcomes calls it, the “only viable solution” for storing data, but that storage must be centralized and secured. Any third-party server service must comply with all applicable HIPAA requirements.

The law also requires you keep audit logs and regularly review audit trails, which means keeping track of those who accesses your organization’s e-PHI and how. Most information management systems include tools for meeting these requirements, but it’s up to you to establish exactly what information the audit log collects and what constitutes “regular” audit trail review. Let risk analysis guide your decision. Don’t wait until a security breach forces you to take too little action, too late.

5. We have HIPAA agreements with outside parties who deal with our PHI.

Server providers aren’t the only third parties you have to be sure are in data compliance with HIPAA. Any person or entity outside your organization who interacts with your PHI—answering services, medical transcriptionists, accountants, medical coding and billing services, data analysis, document storage or shredding companies, practice management, and more—is your “business associate” in the law’s eyes and must obey all applicable privacy regulations.

You must obtain a written contract or other document containing satisfactory assurances that your business associates and any of their subcontractors will safeguard your organization’s PHI and only use it as needed to perform its responsibilities to you. HHS makes a model business associate contract available online. You can also find decision trees online, such as this one, to help you clarify who counts as your business associates and who doesn’t.

6. We train and monitor staff HIPAA compliance on an ongoing basis.

HIPAA requires healthcare organizations to train staff in both the HIPAA Privacy Rule and the HIPAA Security Rule, but doesn’t spell out specific requirements. The HHS OCR offers free resources to help you plan training. HIPAA Journal lists helpful “dos” and “don’ts,” and points out that though HIPAA training may feel burdensome, the potential financial cost if you’re not providing it could be devastating.

Your responsibility doesn’t end with HIPAA training for employees. The law makes explicit your obligation to monitor staff for HIPAA compliance. Without an internal monitoring program, you expose yourself to substantial financial risk (one non-compliant organization paid HHS a $5,500,000 resolution amount). Fortunately, a staff aware of required compliance monitoring can help you stop violations—like shared login credentials, unattended devices or documents, or curious “nosing around” in patients’ charts—before they occur.

Don’t Stop Strengthening Your Practice With HIPAA Data Compliance

Taking stock of and, if necessary, improving your e-compliance with HIPAA is vital to your organization’s legal and economic health. And who knows? HIPAA data compliance now may give you an advantage should the U.S. move toward stricter, GDPR-like standards in the future.

Improving practitioners’ medical documentation and coding skills is another smart investment you can make in your organization, and MDCodePro is the tool you need to help you do it. To learn more about how MDCodePro can make your organization’s coding more accurate, more compliant with regulations, and more profitable, fill out this form.

The post Measure Your HIPAA Data Compliance Against This Checklist appeared first on MDCodePro.

source https://mdcodepro.com/blog/hipaa-data-compliance/

Why Your Practice Must Be Tracking Denied Medical Claims More Closely

Don’t ignore clues to improvement in the frustrating claims that come back.

In some contexts, 5-10% might not seem like much.

In U.S. healthcare, however, 5-10% is the average medical claim denial rate, and it means a lot of lost time and money for hard-working providers like you.

What percentage of your submitted claims are rejected? Unless your answer is a miraculous “zero,” you’re probably unhappy with your denial rate.

But complaining changes nothing. As the AMA’s National Health Insurer Report Card shows, commercial insurers deny anywhere from 1.38% (Regence) to 5.07% (Anthem BCBS) of claims. Medicare denies 3.78%.

A denied medical claim tracking system can help you deal with denied claims more constructively.

“Only about two-thirds of denials are recoverable,” writes the Advisory Board’s Morgan Haines, “but almost all (90%) of them are preventable.” Instituting and following a strong system for tracking denied claims is the first step you can take toward getting fewer of them.

Tips for Dealing with Denied Claims

We’re strong advocates of improved E/M service documentation at MDCodePro, so we appreciate efforts to better document other areas of your medical practice, too.

Here are a few pieces of advice for tracking denied medical claims and turning them to your practice’s benefit:

• Keep a denied claims log
  Whether on paper or electronically, a log of denied claims is an invaluable aid to keeping track of what denials you’ve received and why. Your log should include dates of service, claim numbers, dollar amounts, the exact codes denied, the payer’s written correspondence, and your practice’s response, according to Physicians Practice. In addition to helping you keep records in order, tracking denied medical claims in a log helps you spot any trends faster when you analyze the data (such as every month). You’ll be able to take corrective action sooner and stop losing revenue for repeated mistakes.

• Plan your appeals policy
  Appealing denials costs time, energy, and money you’d rather be spending treating patients. Some 50%-65% of denials are never worked, reports Medical Group Management Association. And with each claim costing $118 on average to work, it’s no wonder. Unless your denial rate is extremely low, you won’t be able to revisit every denied claim. So decide in advance which ones you’ll pursue. Communicate whatever criteria you choose—an amount of money, a specific service, or others—to your accounts receivable or other appropriate administrative staff. Invest your appeals resources wisely.

• Educate around denied claims
  No matter how many denials you appeal, your practice can learn from all of them. What do the claims suggest your practitioners or coders should focus on? Verifying patient eligibility? Checking to see whether a claim has already been submitted? Making documentation more complete, or even more legible? Choosing the correct ICD-10 or CPT®  code? (Some codes change annually, as Dr. Sherif Hassan told Software Advice, so keeping current is one good way to stop potential denials before they happen.) Targeted training and continuing education can help you correct these common medical claim denial reasons.

Prevent More Claim Denials with the MDCodePro Method

What other reasons cause claims to be rejected? Careful medical claim tracking often reveals questions about a procedure’s medical necessity lead to denials. Payers’ inconsistent use of the term is part of the problem, but so is physicians’ insufficient documentation.

The MDCodePro app can help you make sure you’ve documented medical necessity with enough accuracy and in enough detail to support your practice’s billing claims. Our video lectures introduce you to simple strategies for documenting medical necessity, and our code generator guides you, step by step, in choosing any visit’s optimal CPT®  code.

We can’t promise you’ll never see another denied claim. But we can tell you that following the MDCodePro method, validated in audit after audit, is one of the best things you can do to reduce your risk of denied claims and increase your legitimate revenue.

Discover the difference MDCodePro can make to your practice’s performance. Sign up for your subscription today.

The post Why Your Practice Must Be Tracking Denied Medical Claims More Closely appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-claim-tracking/

Are You Documenting and Coding Chronic Conditions the Best Way?

Exercise this option to support higher CPT® codes when needed.

In their paper arguing for longer “routine” primary care visits, Dr. Mark Linzer and colleagues describe “[a] 78-year-old widow with hypertension, osteoarthritis, a recent stroke, elevated cholesterol, and a 50-pack-year smoking history [who] comes to her primary care provider for a mild cough and weight loss.”

Patients don’t always visit you for the reasons they most need to visit you.

So how do you handle documenting and coding chronic conditions in fully accurate, regulatory compliant, revenue-generating ways during an established patient visit?

Chronic Conditions: Increasingly Common and Costly

The HHS defines chronic conditions as “conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living.”

About two-thirds of Medicare beneficiaries live with multiple chronic conditions, compared to one-quarter of the U.S. population generally. The five chronic conditions most commonly found among Medicare beneficiaries (according to the 2012 edition of CMS’ chronic conditions chartbook) are:

• high blood pressure (58%)
  
• high cholesterol (45%)
  
• heart disease (31%)
  
• arthritis (29%)
  
• diabetes (28%)

Common chronic conditions that should always be coded include hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson’s disease, and diabetes mellitus.

Coding chronic conditions is key to not only your patient’s care but also your practice’s revenue. “Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition,” the CDC reports. “Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending.”

Only thorough documentation meeting CMS guidelines will ensure you see the share of that spending you deserve for treating patients with chronic conditions. “If critical information is not documented during each patient encounter with the chronically ill,” coding expert Valerie Fernandez wrote for ICD10monitor, “a physician will lose revenue.”

Using Extended HPI to Document Chronic Conditions

Your most reliable tool for documenting and coding your established patients’ chronic conditions is the extended history of the present illness (HPI).

Under CMS’ 1997 E/M services guidelines, you may document an extended HPI by noting the status of three or more chronic conditions to support higher levels of care for established patients and the higher CPT® codes associated with that care. (In 2013, CMS expanded this option, allowing it to satisfy HPI documentation whether providers followed the 1995 guidelines or the 1997 guidelines.)

“The key to this option is the status,” coding and billing expert Rebecca Caux-Harry wrote for 3M Health Information Systems. “A provider can’t point to a problem list as satisfying the HPI requirement, as the problem list doesn’t usually document the status of each issue.”

That’s why, as Dr. Alexander Stemer stresses in his MDCodePro video lectures, “language counts.”

Naming the chronic condition isn’t enough. You must also describe it. The history you document should “paint the picture” of the patient’s complexity and risk, and chronic conditions play a big part in what that picture ultimately looks like.

“Controlled” and “uncontrolled” are appropriate statuses for most chronic conditions, but they don’t exhaust all your options. “If it’s ‘new,’ always say that,” Dr. Stemer advises, “as that descriptor significantly impacts scoring. If the problem is ‘acute,’ ‘severe,’ or ‘worsening,’ state that. If your patient’s asthma attack is severe, record ‘acute bronchospasm, severe, persistent.’ If a problem interferes with function, such as severe arthritis preventing stair climbing, record ‘no longer able to climb stairs,’ or ‘unable to shop for food.’”

“Saying it at the beginning of the visit,” Dr. Stemer teaches, “helps your scoring at the end.”

Meet CMS Coding Guidelines for Chronic Conditions with MDCodePro

Showing you how to efficiently and effectively incorporate an extended HPI into your professional routine is only one way the MDCodePro system can help you better document all your patient visits, including those “routine” ones, like the visit Dr. Linzer described, that you soon realize aren’t.

When you put the method we show you into practice, you may sometimes have more documentation than the CPT® code your established patient’s visit requires, but you’ll never have less.

The number of chronic conditions today’s patients face means you should probably be submitting higher CPT® codes more of the time. Be ready to support those claims with MDCodePro. Sign up for your subscription now.

The post Are You Documenting and Coding Chronic Conditions the Best Way? appeared first on MDCodePro.

source https://mdcodepro.com/blog/coding-chronic-conditions/

Avoid These Common Problems Revealed by Medical Coding Audits

Keep these perennial pitfalls in mind for your internal auditing.

The AAFP tells healthcare organizations keeping their error rate (the percentage of claims payers deny) below 5% is “desirable.”

Hitting that target is hard. One consultant and auditor, Jacqueline Thelian, told For the Record she’d seen “maybe five clients” reach 95% accuracy in 27 years.

Internal coding audits can help you bring your error rate down. Yes, they’re time-consuming and costly, but it’s better to find problems before third-party medical coding audits do so you can fix them.

Better yet? Prevent coding problems in the first place. Fewer errors mean not only increased compliance with coding guidelines (meaning less regulatory headache down the road), but also more accurate patient records (meaning they get better care) and greater revenue for the services you provide (meaning a healthier bottom line for your organization).

We developed MDCodePro to help busy practitioners like you achieve these goals. And we’re happy to point out additional helpful resources when we find them.

So we wanted to spotlight coding consultant, educator, and auditor Terry Fletcher’s four-part series for ICD10monitor earlier this summer, “Auditing Issues Uncovered in Physician Documentation.”

Fletcher has over three decades of experience in medical coding, including regional and national service to the AAPC. She even hosts her own medical coding podcast. She’s well qualified to discuss the problems medical coding audits bring to light.

Reading her catalog of common pitfalls would be a great first step toward developing a medical coding audit policy for your organization. Fletcher offers both high-level overviews of areas where practitioners and coders get into trouble and several specific traps to look out for (for example: Only physicians can document the HPI—never medical assistants). Although she’s a specialist in the ICD-10 diagnostic codes, virtually all her advice holds true when dealing with CPT® codes, too.

You’ll be glad you spent time reading Fletcher’s whole series. For now, here are just a few cautionary takeaways to remember as you plan your internal coding audits:

Resist the Temptation to Undercode Patient Visits

Hopefully, you already know deliberately downgrading codes in hopes of avoiding audits is more than a bad idea. It’s every bit as fraudulent as upcoding.

There’s no guarantee this misguided strategy even works. As Fletcher writes, “assigning codes lower than what is supported by the documentation . . . can be as much of an audit flag as coding all level 4’s and 5’s.”

When you use a sound, validated methodology such as MDCodePro’s, you don’t have to be afraid to claim higher codes when appropriate. You’ll have all the documentation you need, and sometimes more than enough, to back whatever CPT® code the visit’s complexity and risk demands.

Hold Your Medical Histories to High Standards

Fletcher mentions she’s heard some doctors recommend eliminating the history from charts. Last year, even CMS considered removing E/M documentation requirements for the history and exam and relying on medical decision-making (MDM) and time as determining criteria instead.

But she argues the history is vital in establishing medical necessity: “It can lay the groundwork for the physician’s ‘right’ to move forward with the exam and medical decision-making.”

Make comprehensive histories your professional habit. MDCodePro shows you how easily you can. When you document a comprehensive history for your patients, as you were taught in medical school, you’ll have a better understanding of their complexity and risk, and a firm foundation for assigning the corresponding CPT® code.

Use Electronic Medical Records’ Code Selection Software Sparingly

EMR systems’ tendency to make copy-paste mistakes too easy to commit is only one reason providers must proceed with caution. Fletcher points out many problems she’s seen in medical coding audits result from these systems’ code selection software.

Wrong information about codes, difficult user interfaces, and missing features (including an alarming inability to recognize conflicting information in the chart), coupled with clinicians’ ongoing unfamiliarity with CMS’ E/M documentation guidelines, leave EMR coding software an only partially reliable resource for choosing codes.

Instead of relying on flawed EMR code selection software that could leave you liable for mistakes, use an app dedicated to guiding you through the process step by step while teaching you the “why” behind the “what” of CPT® code assignment.

Ace Your Internal and Third-Party Coding Audits with MDCodePro’s Help

“CPT® and ICD-10 coding do become less risky when documentation is done properly,” Fletcher writes.

We agree. As important as internal audits are, strengthening your documentation skills is critical to heading off mistakes found during third-party audits. When you document patient visits more accurately and completely, you’ll code them more correctly.

MDCodePro trains you to do just that. Our video lectures streamline CMS documentation guidelines so you can easily build them into your daily professional routine, and our code generator uses the information you input (not data imported automatically from charts) to point you to each visit’s most accurate, compliant, and revenue-increasing code.

Find out your current coding challenges. Then let MDCodePro help you correct them so your next medical coding audit finds you giving better patient care and capturing more of the revenue you’ve earned. Start your MDCodePro subscription today.

The post Avoid These Common Problems Revealed by Medical Coding Audits appeared first on MDCodePro.

source https://mdcodepro.com/blog/medical-coding-audits/

How to Get Better Documentation for Improved Health Risk Appraisals

Discover two coders’ keys for getting better information from doctors.

What advice would you give the medical coder who asks, “My doctor only wants to list the primary diagnosis. How can I convince her to document the significant comorbidities?”

It’s a common problem. When physicians perform health risk assessments of Medicare beneficiaries, comorbidities and other relevant information don’t always get documented.

In fact, providers fail to report over 40% of active chronic conditions, the AAPC reports. And CMS doesn’t validate over 30% of the HCC (Hierarchical Condition Categories) codes used in risk adjustment “due to lack of supporting documentation.”

At MDCodePro, we hear a lot about coders’ frustrations with physicians. But frustration can run the other way, too.

“Coders and doctors are operating with two separate languages: clinical language and administrative language,” Dr. Robert Donnell writes for the KevinMD blog. “Clinical language tells the patient’s story and acknowledges all the uncertainty in the clinician’s reasoning process. You lose a large piece of that when you try to reduce that story to a list of codes.”

We’re convinced the physician-coder gap can be bridged. You can get your doctor to document comorbidities, and a lot of other information they might not currently be documenting. But to get what you need, you must first look at the situation from the physician’s point of view.

Then you’ll be more likely to help them see how the information you need is the information they—and even more significantly, their patients—need, too.

Why Comorbidities Matter in Health Risk Appraisals

Comorbidity documentation makes an excellent case in point.

One in four adults in the U.S. suffers from comorbidities (two or more chronic diseases or conditions at the same time)—for Americans age 65 and older, that figure jumps to three in four—and these comorbidities make care more complex and costlier.

Research from CMS shows “Medicare expenditures on patients grow non-linearly with the number of comorbid conditions,” driving expenses higher at a dramatic rate. The 2017 edition of Multiple Chronic Conditions in the United States reports Medicare spends $8,867 annually on patients with three or four chronic conditions, compared with $5,272 on those with one or two, and $17,640 on those with five or more.

Medicare risk adjustment takes the differences between patient populations into account when evaluating providers’ performances. CMS requires qualified providers conduct annual Medicare health risk assessments of patients to establish “a ‘base year’ health profile for those individuals,” explains the AAPC, and “to predict costs in the following year” for treating them.

As U.S. health care reimbursement shifts toward a value-based model, “risk adjustment can greatly affect physician income,” writes Duke University Hospital’s Dr. John Yeatts, “so it is important to get it right.”

Looking at Documentation as a Time-Strapped Doctor

Do physicians know about comorbidities? Of course.

Do they want to assess patients’ health and well-being accurately? Yes.

Do they know what they document affects the amount they get paid? Guaranteed.

But “getting to the point” and listing only the primary diagnosis may seem like a good choice because their time is so limited, and many feel they already spend too much of it on paperwork.

Doctors spend two hours on EHR maintenance and other desk work for every hour spent with patients, according to a study in the Annals of Internal Medicine. And only slightly better than half of time with patients (52.9%), as during the Medicare annual wellness visit, is “direct clinical face time;” 37% goes to the EHR. What’s more, physicians spend another one to two hours each night doing paperwork on their own time.

So coders shouldn’t be surprised if doctors feel rushed and resistant to requests for even more documentation.

“Medicine traditionally puts the patient first,” Dr. Danielle Ofri wrote for the New York Times. “Now, however, it feels like documentation comes first. What actually transpires with the patient seems like a quaint trifle, something to squeeze in among the primary tasks of getting everything typed into the E.M.R.”

Empathy and Education: Two Keys to Better Documentation

Granted, seeing the situation from a doctor’s perspective doesn’t change the need for robust documentation. But taking the time to empathize can go a long way toward getting your requests for more information heard and answered.

You also need to translate your queries into concrete benefits for both patient and practice. “When querying a physician regarding the medical record,” clinical documentation consultant Gina Stewart, RN told For the Record, “you will never obtain positive results in the long run if you do not educate them on the eventual outcome and purpose” behind your query.

A coder concerned with getting a doctor to list comorbidities can point out how healthy the practice’s patient population appears in records “impacts [the practice’s] profile on outlets such as Healthgrades, Consumer Reports, [CMS], and insurance providers,” as Dr. Drew Siegel told For the Record. If documentation doesn’t reflect patients’ true acuity, not only will patient care suffer; so will the practice’s risk adjustment and reimbursement.

A list of comorbidities belongs in an accurate assessment of patients’ health and well-being, and supports the argument about higher patient acuity. When patients’ conditions are more complex, physicians must use more complex medical decision-making in diagnosis and treatment. The result? Patients are more likely to get the treatment they need, and providers are more likely to be appropriately paid for it.

“Physicians need help understanding that their responsibility for quality outcomes lies in the pen used to provide medical record documentation,” Krauss and Epstein wrote. “Once they understand this, they’ll write what’s true”—including significant comorbidities.

Build Better Documentation into Everyday Routine with MDCodePro

To thoroughly transform documentation in your practice, you’ll have to do more than empathize with busy doctors’ frustration and explain the concrete benefits better records bring to patients and practice. You’ll also want to equip everyone with a simple but powerful way to make stronger documentation and optimal coding a part of the everyday routine.

MDCodePro is the perfect tool for achieving this goal.

It’s really two solutions in one convenient app, suitable for use in both desktop and mobile browsers: a brief series of video lectures presenting a streamlined, simple-to-remember way of documenting patient encounters in a way that makes the most of CMS guidelines, and an easy-to-use code generator that presents the optimal CPT® code for any encounter, from the Medicare health risk assessment to a post-op follow-up, based on the information you input.

With MDCodePro, higher quality documentation becomes an easy and integral part of the daily workflow for physicians, coders, and administrators—not an extra burden anyone has to feel frustrated about.

Sign up for your subscription today and start seeing the difference MDCodePro can make to your practice and for your patients.

The post How to Get Better Documentation for Improved Health Risk Appraisals appeared first on MDCodePro.

source https://mdcodepro.com/blog/medicare-health-risk-assessment/

How Can You Help Your Physicians Learn Medical Coding?

Discover How to Avoid Frustration Coders and Physicians Face

If you’re a medical coder or coding administrator feeling frustrated by “incomplete and nonspecific” documentation…

Or fed up with patient charts “replete with errors and discrepancies”…

Or you despair of bridging a “communication divide” between coders and physicians…

…you’re not alone!

These frank descriptions come from Dr. Karen Tang and colleagues’ interviews with 28 medical coders. They spotlight what those coders see as “physician-related barriers to producing high-quality administrative data.”

How can coders and physicians move past these barriers?

Physicians didn’t take medical coding and billing courses in med school. “The truth is,” Dr. Adele Towers writes for AHIMA, “that most physicians have no idea what CDI [clinical documentation improvement] means and why it should be important to them.”

That’s why the best way to get physicians to help you achieve improved coding is to show how and why what you do helps them.

As Todd Kislak writes for H&HN, “[A]nswer the ‘What’s in it for me?’ question that physicians often ask silently or aloud. Do this for your physicians and watch them improve their documentation.”

Here at MDCodePro, we want to be a resource for coding professionals looking for better ways of working with physicians. We know coders frequently feel frustrated by the difficulties they face getting enough details from doctors for choosing a specific code.

Sometimes the “not enough detail” affliction can feel like a chronic condition no coder can cure! But here are a few ways to move past physician-coder frustration toward improved documentation—and toward more accurate and regulatory compliant coding, as well as more revenue for the practice.

Implement Standard Query Procedures

You’re more likely to get the details you need from doctors if you present your follow-up questions the same way every time.

Models for doing so exist. As the AAPC points out, CMS “has adopted query guidance for hospital needs, but there is nothing in the guidance to indicate queries are only for hospitals. So why not use them in the physician office?”

Stick with standard query formats—open-ended, multiple choice, and yes/no—use standard templates, keep queries brief and relevant to a specific date of service, and ask in a timely fashion (the AAPC recommends within 30 days of the initial documentation.)

Be certain you’ve told physicians about query practices you adopt, and don’t be reluctant to remind everyone about standard query protocol once in a while.

Stick Close to Physicians

No matter how much you enjoy your work, you don’t want to sit behind your computer with doctors’ notes and patient charts all day long, right? Why not be where the action you translate into diagnostic and billing codes is taking place?

“Sometimes,” professional coder Mary Pat Whaley told Physicians Practice, “physicians can… benefit from having a coder shadow and scribe the [patient] visit in addition to the physician’s documentation to compare what each comes up with. You would be surprised how often a physician forgets to say, ‘I reviewed the… lab results, X-rays, consultation report, etc.’ It’s something very simple, but, if it wasn’t documented, it wasn’t done.”

If shadowing doctors during visits isn’t an option, you may still be able put yourself in a better place—literally—for catching documentation mistakes. One coder told the AAPC sitting near physicians’ offices “has helped me out tremendously as I can hear my doctor dictate his surgeries, office visits, etc., and will catch some things before they are billed out incorrectly.”

Take Your Teaching Role Seriously

You may not see yourself as an educator, but you may be the closest some physicians ever come to taking a medical coding and billing course.

Take and make opportunities to tell them what information you need from them and especially why: so patients receive the most appropriate care possible, so records of the care comply with all regulations, and so the practice receives all the revenue it deserves for providing the care.

Being a teacher doesn’t mean being condescending, but it does mean being direct. “Physicians are by nature independent thinkers,” writes Dr. Towers, “and will expect a very concise, clear reason to change documentation habits.”

Physicians “will, and do, support CDI efforts,” write Glenn Krauss and Dr. Jeffrey Epstein for the Association of Clinical Documentation Improvement Specialists, “when such efforts are distinctly tied to excellent care and achieving the best outcomes for their patients.” The more specific and substantive your explanations, the better.

Offer Physicians a Realistic, Relevant Medical Coding Training Program

While physicians don’t have time to meet the same medical coding and billing certification requirements professional coders meet, their ongoing education can include training in medical coding—especially when that training is accessible, flexible, and useful in their daily work.

MDCodePro is an online medical coding and billing course and app (for desktop and mobile browsers) designed to bring that kind of coding education within your physicians’ reach.

Its short series of video lectures provides them a streamlined way to learn medical coding online, and its step-by-step code generator lets them put what they’ve learned into practice right away.

Best of all, a vigorous emphasis on improved documentation runs through it all. The MDCodePro methodology will make the doctors you work with better at thinking through the patient’s risk and their medical decision-making in their notes—which means they’ll give you, in the right way, more of the information you need to make the best coding calls for your practice and its patients.

See for yourself how MDCodePro can help clear away those frustrating barriers physicians and coders too often face. Sign up for your subscription today.

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source https://mdcodepro.com/blog/medical-coding-billing-courses/