An Organized Way of Working

1. An Organized Way of Working If we have to live with the rules the insurers make, we might as well learn to work with the rules

2. Learning Points • Being an excellent Family Physician depends more on having the right tools than having the best knowledge • Documentation requirements were established with no evidence that they are equitable or achieve quality • Thinking about documentation requirements after the visit ensures that you will be undercompensated for your care • Some documentation rules can be used to prompt you to structure your care so that quality improves

3. The quality chasm between primary care and subspecialists • “Why would you waste your career on Family Practice?” the Dean • “You won the battle but lost the war. It’s not what we know, it’s what we do!” George T. Wolff, M.D. • In court, you are held to the same “standard of care” as any other doctor • In order to accomplish this standard, the Patient Centered Medical Home says we need to organize our practices to create this • This presentation talks about how you can organize yourself so you can do your part in creating excellence.

4. Those with the gold write the rules • In 1960, GPs were paid 70% of the highest paid specialty in the US • In 1980, FPs were paid 50% of the highest paid • In 2009, FPs are being paid 25% of the highest • We have not learned to “play by the rules!” • Barbara Starfield has shown that the best quality and lowest costs are found in places with the highest ratio of FPs to population • PCMH says we have to learn to work with the rules to achieve demonstrable quality so we can increase FP compensation 50-100%

5. What are the rules? • Patient is new or established • Location of the service • Type of service • History • Exam • Medical Decision Making • Rules are the same regardless of specialty • FPs have regularly underestimated their work

6. History • Problem Focused - PF • Expanded Problem Focused – EPF • Detailed – D • Comprehensive - C

7. Physical Exam • Problem Focused - PF • Expanded Problem Focused – EPF • Detailed – D • Comprehensive - C

8. Medical Decision Making • Straight Forward – SF • Low Complexity – LC • Moderate Complexity – MC • High Complexity – HC Must have 2 of following 3 components • Problems – Limits – 1 new problem, 2 minor problems • Data Analysis – Seldom drive MDM in office • Risk – FPs generally under estimate this!

9. Rational Physician approach to documentation and coding • Start with Medical Decision Making to choose your service code • Document History, Exam, or Time to support the code • New Patient – 3/3 • 99201 – SF • 99202 – SF • 99203 – LC • 99204 – MC • 99205 – HC • Established Patient – 2/3 • 99212 – SF • 99213 – LC • 99214 – MC • 99215 – HC

10. Starting with the end in mind • Separate history by problem • (Have staff record history elements physicians notoriously forget, e.g. date of injury, location of symptoms, severity, & associated S/S) Physician should generally record Radiation, Quality, Context, & Relieving & exacerbating factors • Multiple diagnoses with description of certainty and/or interrelationships – No Naked Diagnoses! • Record all of your plan!

11. Future Lessons • Week of: • August 17 – Getting the History Right • August 24 – Documenting PE, Data, & Writing Scripts • August 31 – Assessment & Plan • September 14 – An excellent single problem note • October 13 – Documenting Prevention Visits • November 3 – Managing Multiple Problem Visits

12. This week’s practice focus • Is your note clear? I.e. If you had not been in the room, would you be able to read your note and have a good idea of what the visit was about? • Have you eliminated resolved ambiguity? I.e. The patient often presents with a jumble of concerns that your interview resolves. Have you recorded the jumble or the resolved clarity? (Remember, reality is often ambiguous even after you’ve done your best!) • Is your note succinct? Skilled clinicians only record 10% of information exchanged in a visit. The rest is “chaff” that does not inform.