With medical decision making defining the level of visit, accurate documentation is integral to establish the complexity of visit for medically appropriate RVUs.
Medical decision making (MDM) is arguably the most important part of patient care. Clinicians leverage their experience, knowledge, judgement, and consider a wide range of perspectives to make the best medical decisions. Ultimately, they devise a treatment plan that is in line with the patient’s desired outcome. Evolving payer policies and shifts in reimbursement models demand accurate MDM documentation to validate the level of visit and ensure precise level of coding. Omega Healthcare’s clinical documentation improvement led coding solution helps enhance the integrity of MDM documentation leveraging advanced AI platforms. The actionable feedback on ways to improve clinical documentation enhances physician-focused coding.
Why Good Intentions are Not Enough
Medical decision making weighs significant variation in risk and outcome preferences among patients, providers, and payers. Physicians must have a thorough understanding of the underlying disease processes and most up-to-date treatment options. They must also consider problems that other physicians are primarily managing while formulating the management plan. Medical decision making often relies on conflicting, uncertain, or small volumes of data. While a physician’s service may seem simple, the complexity of evaluating medical decisions necessitate putting guidelines and processes in place to ensure the highest quality outcome.
Physicians can confidently establish the acuity and severity of a problem. However, they must document the nature of presenting problem, patient’s condition, any supplementary data, and corresponding plan of care. A step required for each visit, not just for reimbursement, but to let next physician know what they were thinking. Physicians must record detailed notes defining the reasons for considering a particular diagnosis/treatment over other possible diagnoses/treatment. While the patient’s condition or problems may not change dramatically during a given day of hospitalization, physicians must record all changes and services provided at each visit with service dates to establish the complexity of the case during medical record audits.
Understandably, the administrative burden of documentation overwhelms physicians, takes time away from patients, and subsequently leads to burnout. However, there are risks with deficient documentation too: Documentation may fail to corroborate appropriate management of a particular problem, diagnosis, testing, or treatment strategy. This can result in downgrade of the apparent complexity of visit, reduction in RVUs, and less effective care for patient.
The launch of “Patients over Paperwork” initiative allows physicians to select E&M services based on total time spent on the day of the visit or the level of medical decision making. This makes MDM one of the key factors in defining the level of service. The new guidelines require physicians to be more detail-oriented while documenting MDM. They must describe the management of a diagnosis as opposed to just selecting the diagnosis. For example, physicians must record the number of diagnoses and/or management options they must consider as well as the amount and/or complexity of medical records, diagnostic tests, and/or other data they must obtain, review, and analyze.
Capturing Crucial Elements of the Visit
Either the date of visit and total time spent including non-face-to-face work done on same day or medical decision making, and no longer the percentage of time spent counselling/coordinating care.
- Nature of service ordered, planned, scheduled, or performed at the time of visit.
- Any decision to obtain outside records or additional information from patient’s family, caregiver, or other sources.
- Discussion of results of each individual lab/radiology/diagnostic tests and if discussed with the physician who performed or interpreted the studies.
- Discussion of management with another person or surrogate decision maker.
- Any diagnosis, assessment, or clinical impression explicitly stated or implied for management plans and further evaluation. Alternatively, “differential diagnosis”, “possible”, “probable”, or “rule-out” if a diagnosis is not established.
- Document every problem with a diagnosis, and also if the problem is well controlled, resolving, resolved, or having an exacerbation, progression, or side effect.
Leveraging CDI to Optimize MDM Documentation
Comprehensive physician documentation alone validates the intensity of consideration put into the medical decision making. Omega Healthcare’s clinical documentation improvement led coding solution helps physicians significantly reduce the administrative burden of tedious MDM documentation. The CDI solution uses advanced NLP and ML platforms to scan through charts and provide near real-time, actionable, individual chart specific CDI feedback to improve MDM documentation. The clinically focused and AI-driven cognitive engine provides non-intrusive alerts and tips that focus on driving compliance and improving revenue. The clinical documentation improvement solution also provides physicians with performance reporting on compliance, customized education materials, and comparative dashboards on deficiency levels in a simple and meaningful way.
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