Course 320 Documentation with trainees and leveraging the EHR

1. Course 320 Documentation with trainees and leveraging the EHR Mark Huang, M.D. Chief Medical Information Officer Rehabilitation Institute of Chicago Associate Professor Department of PM & R Feinberg School of Medicine Northwestern University

2. Disclosures No personal disclosures The Rehabilitation Institute of Chicago has collaborated with Cerner Corporation in the development of rehabilitation content and serves as site for reference calls and visits

3. Objectives • Discuss documentation requirements when working with trainee • Analyze examples of leveraging the EHR • Documentation • Orders • Discuss implications of meeting meaningful with assistance of the trainee

4. CMS guidelines • Clear identification that you are the teaching physician • Bill with GC modifier • When you bill E/M services, you must personally document at least the following: • You performed the service or were physically present during the critical or key portions of the service furnished by the resident • Your participation in the management of the patient. CMS manual system pub 100-04 transmittal 2303

5. Reimbursement • Evaluation and management codes • level of service is combination of what resident documents as well as attending • Procedure codes • based on combined services of resident and TP • Modifiers: • Attach GC modifier

6. GC modifier • Definition • Service has been performed in part by a Resident under the direction of a teaching physician. • Appropriate Usage: • When the Resident performs a service in a teaching facility under the supervision of a teaching physician. • Inappropriate Usage: • When the teaching physician is not involved in any portion of the service

7. Scenario 1 • Teaching physician personally performs all required elements for E/M service (office visit) • Resident may or may not have performed E/M services • TP note references resident note • Must document performed the critical or key portion(s) of the service, and that he/she was directly involved in the management of the patient • If NO resident note, TP must perform all required documentation

8. Scenario 2 • The resident performs office visit in the presence of, or jointly with teaching physician; resident documents the service. • TP documents that he/she was present during the performance of the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient. • TP note should reference the resident’s note.

9. Scenario 3 • The resident performs some or all required elements of the service separately from TP and documents his/her service. TP independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. • TP documents that he/she personally saw patient, personally performed key portions of service, and participated in the management of the patient. • The TP note references the resident’s note.

10. Scenario 4 (mainly inpatient) • Resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day: • TP documents that he/she personally saw the patient and participated in the management of the patient. • TP may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note.

11. Scenario 4 • TP note must reflect changes in the patient's condition and course at the time the patient is seen by the TP. • The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making

12. PROCEDURES • Procedures • You must be present for key portions of the procedure • If procedure is brief (less than 5 minutes) you must be present for entire procedure to bill for service • Resident can document procedurebut should state who was supervising physician • While not specifically stated, best for attending to co-sign note and state their presence during procedure

13. Medical students • Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements. • You may only refer to the student’s documentation of the ROS and/or PFSH. • For the HPI, exam, and decision making you must personally document these elements

14. Medical student documentation • You must verify and re-document the history of present illness, and perform and re-document the physical examination and medical decision making activities of the service.

15. Acceptable Phrases • “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.” • “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

16. Acceptable phrases • “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.” • “I saw the patient with the resident and agree with the resident’s findings and plan.”

17. Acceptable phrases • I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with lumbar stenosis. Will begin PT.” • “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.” • “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

18. NOT acceptable • Agree with above • Rounded, reviewed, agree • Discussed with resident, agree • Patient seen and evaluated • Signature alone

19. Leverage EHR with resident • Use of note templates • Automated TP linking statements • Create autotext phrases • Use of macros • Order sets

20. Medicare and the EHR • “You may use a macro, a command in a computer or dictation application in an electronic medical record that automatically generates predetermined text that is not edited by the user, as the required personal documentation if you personally add it in a secured or password-protected system.” • In addition to your macro, either you or the resident must provide customized information that is sufficient to support a medical necessity determination.

21. Medicare and the EHR • The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. • If both you and the resident use only macros, this is considered insufficient documentation.

22. Use of templates • Create templates for common complaints • Generic template for patients that “just don’t fit a template” • Use them as education tools for residents as to common areas to assess and address

23. Templates: HPI

24. Templates: EXAM

25. TEMPLATES: PLAN

26. Documentation in EHR • Create separate note referring to resident note • Addend or modify resident note • Best to make clear what is your documentation

27. Teaching physician attestations

28. Examples of autotext Outpatient Inpatient

29. Combined notes OUtpatient Inpatient

30. Procedure notes

31. Documentation training points • Train residents in learning to appropriate update each note to reflect the current visit • “Copy and paste” wisely • Identify original source if they were not original author • Make it clear in documentation what was done on today’s visit • BOLD or ITALICS • New paragraph with date

32. Perils of cut and paste • A real issue of concern • Increased scrutiny from CMS and private insurers • Denial of payment, concerns of fraud • 2003 study in VA • 50% notes contain cut and paste • 10% felt to be high risk: “Human, clinically misleading, major risk” Hammond, KW, AMIA Symposium Proceedings 2003

33. Examples of bad cut and paste Hammond, KW, AMIA Symposium Proceedings 2003

34. Appropriate cut and paste

35. Voice recognition • Voice recognition well suited for attending attestations • Dragon dictation • Dictate your TP addendums right away, add to resident note when completed • Create voice recognition “macros” or autotext” • Caveats: • Watch accuracy • Word subsititution

36. Orders • Create order sets for common outpatient scenarios • Provides resident once place to find common orders • Helpful to establish standards of care

37. ORDER set examples Therapy order set Bone health order set

38. Meaningful use pain points • Medication reconciliation • Visit summary • Patient education • Eprescribe • Electronic physician documentation • Transition of care documents

39. Meaningful use • Educate residents in requirements (they need to know anyway!) • Put resident in charge of completion of these tasks • OK for resident to prescribe, make sure they are configured in your system to do so

40. TIPS to Success • Split tasks • Resident does certain MU components • Starts documentation or orders in room while you are talking with patient • You can complete visit summary while resident starts on next patient • See patients concurrently

41. Tips to success • Appropriate set-up • Adequate number of exam rooms • Spend a few minutes teaching them the templates • When to use • When to “freetext” • Computer/chart access • The more you prepare the resident, the better the note quality= the less you need to document!

42. TAkeaways • Understand documentation requirements for teaching physicians • Use the EHR to promote efficiency • Residents can assist in completion of regulatory requirements such as meaningful use