Category: Electronic Medical Records

Many physicians complain that they make too much money. One of the main sources of all of this unwanted money is from consults by referring physicians. In order to reduce one’s income, one very effective solution is to offend your referring physicians so that they send their patients to other doctors, thus causing them to make too much money. The good news is that electronic medical records make it easier than ever before to offend referring doctors. I’m going to show you how any specialist can use the EMR to achieve that ultimate goal of a lower income.

Confuse them.

In the old days, it was harder to be confusing. We used to dictate our referral letters and it was just way too easy to dictate phrases like “Helicobacter pylori”. This led to referring physicians understanding exactly what you were talking about. With the electronic medical record, it is now much easier to just type “HP”. The result of this is that the referring physician reading your letter now has to figure out, “Does he mean Helicobactor pylori? Or hypersensitivity pneumonitis? Or Hewlett-Packard? Or hypertropic prostate?” Abbreviations are a great way to confuse the readers of referral letters, especially those abbreviations that you make up. So, if the patient has pedal edema, put in your note “The patient had AS” – you’ll mean they had ankle swelling but the referring physician will think you meant aortic stenosis and order a cardiac catheterization! Try to put 1-2 abbreviations in each sentence for optimal effect.

Exhaust them.

When we dictated letters, this was really hard to do because dictating an interminably long letter took a lot of your time. With the EMR, we can now insert 10 pages of irrelevant results into a referral letter with a single mouse-click! There is nothing like making the reader of your letters wade through the last 30 potassium levels dating back to 2009 to tire them out. Many EMRs allow you to import all of the meaningless lab and test results into tabular format that is next to impossible to comprehend – a sure way to get the pesky referring physician to stop referring you more patients.

Disorient them.

A great trick I learned from one of our physicians is to vary where you put your impression & plan in your referral letters. Let’s face it, the referring physician could not care less about your review of systems, physical examination, etc. All they really want to know is what you think is going on and what either you are going to do about it or what you want them to do about it. So, the referring physician will automatically skip all of the irrelevant material and go straight to your impression and plan. By sometimes putting the impression & plan at the beginning of your note and sometimes putting it at the end of the note, you can keep them guessing about where to look. If you really want to disorient them, try sometimes putting your impression and plan in the middle of your referral letter! As an analogy, just think of how confused you’d be if the National Hockey League scores were sometimes in the sports section of the newspaper, sometimes in the arts & entertainment section, and sometimes in the middle of the classified ad section. The only danger is that if your referring physician likes playing “Where’s Waldo”, then he or she might actually enjoy the challenge of finding your impression & plan.

Baffle them.

Try writing your progress notes and referral letters in the same language that your teenager uses to text. Use letters like “u” instead of typing “you” and “r” instead of “are”. You can even abbreviate entire phrases like “IMO” for “in my opinion” and “HTH” for “hope this helps”. Whenever possible, drop verbs out of your sentences. Don’t capitalize anything. And remember, punctuation marks are for sissies.

Dodge them.

If you don’t like the question that the referring physician asked you, do what politicians do in a political debate – answer a different question! So, if you get consulted because of a patient’s chest pain and you are completely clueless about what is causing it, then find something else that you can work up, like their plantar fasciitis. There is nothing like “Dear Dr. Jones, Thank you for referring your patient to me for evaluation of crushing substernal chest pain. On exam, I find heel tenderness. My impression is that he has plantar fasciitis and so I will order an MRI of his ankle.” Although it is possible that the referring physician will think you are a genius for figuring out that plantar fasciitis causes referred pain that can mimic angina, it is more likely that they just won’t understand your letter. Another great way to get them to stop sending you patients.

Insult them.

When a referring physician sends you a patient, try to write your note in such a way to be as critical of their initial work-up as possible. If you get a consult for anemia, try inserting phrases such as: “Unfortunately, the patient’s physicians have not ordered screening colonoscopy as recommended by the American Cancer Society.” Or: “This is a textbook classic case of beta thallasemia minor that any 2nd year medical student should recognize.” If these are too subtle, try something more direct like: “The decision to order an iron level without doing a ferritin level was a really stupid idea.” I actually got a letter with a phrase like that in a consultant’s letter to me and so I never sent a consult to that physician again – if it worked for him, it can also work for you!

Belittle them.

A very effective way to alienate the referring physician is to depersonalize them by using phrases like “PCP” and “OSH”. So, if Dr. Smith, who practices at Mercy Mother of Suffering Sorrows Hospital refers a patient to you for consultation, don’t use Dr. Smith’s name in the letter, instead just put PCP for primary care physician. This will depersonalize the referring doctor and emphasis the fact that you consider him or her to be irrelevant and beneath you. There is nothing like starting your letter by saying “Dear Dr. Smith, Thank you for referring the patient to me. She has shortness of breath and her PCP found a new heart murmur.”. In addition to depersonalizing the referring physician, you can also depersonalize that physician’s hospital. Although Dr. Smith may consider Mercy Mother of Suffering Sorrows Hospital as the center of his medical practice universe, you can remind him that his hospital is just a generic small hospital and THE Ohio State University Medical Center is the true center of the medical universe. Using OSH for outside hospital is a very useful strategy. Try writing something like: “The patient had a cardiac echo at an OSH.” Just think of how irritated you would be if you asked for a consultation and the consultant sent you a letter referring to you as PCP and your hospital as the OSH.

By using some of these simple strategies, you too can reduce your income by cutting off the flow of consults from referring physicians. And your electronic medical record makes it easier than ever before to do it.

May 6, 2017

Once upon a time, long, long ago, physician progress notes were a way of recording the patient’s condition and your treatments in the patient’s chart in order to communicate and ensure optimal care to the patient. You can lament that those days are gone but that will do you about as much good as lamenting that Homo sapiens are no longer Austrolopithecus. The progress note has evolved into a component of the hospital bill. Often times, what we write in the chart is not what we need to take care of the patient but rather what the billing department needs in order for the hospital to get paid.

In a previous post, I described the documentation game, where we use key words in the chart as adjectives to describe the patient’s severity of illness in order to lower the hospital’s mortality index. In this post, I’m going to show you how to use key words in the progress note to increase hospital reimbursement for inpatient care.

When a patient is admitted with an illness, the hospital gets paid by the insurance company (or Medicare/Medicaid) based on the patient’s primary diagnosis and not on how long the patient was in the hospital or how many charges the hospital accrued during the hospital stay. The hospital then gets paid more depending on the number of various comorbid conditions that the patient had at the time of admission – in other words, the sicker the patient, the more the hospital gets paid for any given primary diagnosis. So, in order to get paid as much as possible, the hospital has to be sure that all of those comorbidities are captured in the medical record. The hospital that documents comorbidities the best, wins the game. But there are a few rules to the documentation game:

1. The comorbid conditions have to be documented by a physician. Conditions noted by a nurse, dietician, respiratory therapist, or social worker don’t count.
2. The comorbid conditions have to be documented as being “present on admission”. If these conditions are in the emergency room physician’s note or in the admission history and physical, then they are considered as present on admission. However, if a comorbid diagnosis is identified and/or documented later in the patient’s hospital stay, then the physician has to state in a progress note that the condition “was present on admission”, otherwise, it doesn’t count.
3. Diagnoses that only appear in a test result (lab result, pathology report, x-ray report, etc.) do not count. The diagnoses have to appear in an H&P, progress note, op note, procedure note, or discharge summary.
4. Signs and symptoms don’t count.
5. Lab values don’t count – only the physician’s interpretation of lab values count. So, you can’t just document that “the patient had a potassium of 2.5 so I will order potassium replacement”, instead you have to document that “the patient had hypokalemia so I will order potassium replacement”.
6. The more specific you make the diagnosis, the more points you get and therefore the more you get paid.
7. Using the words “likely, “suspected”, or “probable” in front of a diagnosis counts in the documentation game. You don’t have to know for sure that the patient has that specific condition.
8. Certain words diagnoses that mean everything to you from a clinical management standpoint may mean nothing from a coding standpoint. So (as crazy as it sounds), urosepsis doesn’t count but sepsis does count.

In order to be sure that all of those comorbid conditions that were present on admission are captured in physician documentation, hospitals employ clinical documentation improvement specialists who comb through the charts to hunt for evidence that a patient had a particular comorbid condition that wasn’t documented by a physician. When they find one, they send a query to the attending physician or resident asking if the physician agrees that the condition was present and if so, asking the physician to add documentation to that effect in a progress note. Each of these diagnoses translates to a “risk adjustment factor” (RAF) number and when you add up all of the RAFs, the total score determines how much additional the hospital gets paid for any given admitting diagnosis.

Here are some concrete examples of how you can improve your hospital’s score in the documentation game:

• A patient is admitted with a right lower lobe infiltrate and has type II diabetes with an elevated glucose. The patient also has chronic pain and has failure to thrive. Those two sentences get you 0 points. Now lets see what happens if you use some diagnosis words rather than signs and symptom words in your note: A patient is admitted with a suspected aspiration pneumonia (0.292 points) and has poorly controlled type II diabetes (0.496 points). The patient also has opioid dependence secondary to chronic pain (0.055 points) and has moderate protein calorie malnutrition (0.409 points). Now, those two sentences get you an RAF of 1.242 points.
• A patient is admitted with suspected gram negative pneumonia and hypoxemic respiratory distress  with an increased lactate will get you 0.7028 RAF points and the hospital will be paid for a 2.8 day length of stay. However, if the patient is admitted with suspected gram negative pneumonia and chronic respiratory failure with an increased lactate, you now get 0.9469 RAF points and the hospital gets paid for a 3.6 day length of stay. Even better, if the patient is admitted with suspected gram negative pneumonia and acute respiratory failure with hypoxemia and lactic acidosis, you now get 1.3860 RAF points and the hospital gets paid for a 4.6 day length of stay.
• A patient similar to the last one but has sepsis from a urinary source:
  • “Urosepsis with SIRS, acute hypoxic respiratory distress, and an increased lactate” gets you 0 RAF points and no length of stay days.
  • “Sepsis, acute hypoxic respiratory distress, and an increased lactate” gets you 1.0283 RAF points and 3.8 days length of stay payment.
  • “Sepsis, acute respiratory failure with hypoxemia, and lactic acidosis” gets you 1.7660 RAF points and 4.8 days length of stay payment.

However, Medicare and insurance companies have determined that the documentation game wasn’t challenging enough so they added some more rules to make it harder to get RAF points:

• For patients admitted with pneumonia, you get more RAF points if you can specify the type rather than just documenting “pneumonia”. So for example, “aspiration pneumonia” or “gram negative pneumonia” gets you more points. Don’t forget, that you are allowed to use the word suspected. So, for example, if you are prescribing vancomycin for a patient with pneumonia on the chance that they might have MRSA, put in your note “suspected MRSA pneumonia” rather than just writing “pneumonia”.
• “Altered mental status” doesn’t count for any RAF points (it is a finding and not a diagnosis). So, instead, that patient has “acute encephalopathy” in your progress note.
• “Unresponsive” doesn’t count but “unconscious” does.
• “Drug-induced delirium” is a psychiatric code and doesn’t get you very many RAF points. It is better to document “toxic encephalopathy”.
• If someone has a body mass index > 40, you get more points for documenting “morbid obesity secondary to excess calories” than you get for documenting “morbid obesity” alone.
• For patients with heart failure, you get more points if you add the words “acute” or “chronic” and you also get more points if you add the words “systolic” or “diastolic”.
• Avoid the word “dysfunction” as it doesn’t count for any points. So, for example, a patient does not have left ventricular dysfunction, they instead have left ventricular failure.
• “Do not resuscitate” gets you no points but “palliative care” gets you lots of points. So, if you have a discussion with a patient and the patient decided to not undergo resuscitation, don’t document: “I spoke with the patient and he wants to be DNR“. Instead document: “I had a palliative care discussion with the patient and he wants to be DNR“. The terms comfort care, end-of-life care, and hospice care are all considered synonymous with palliative care when it comes to RAF points.
• To maximize your RAF points, nobody should have “dementia requiring a sitter”. They should always have “dementia with behavioral disturbance”, “dementia with aggressive behavior”, “dementia with violent behavior”, or “dementia with combative behavior”.

The documentation game is by necessity a team sport and the team that wins will have both the strongest physician and the strongest documentation specialist. But it is not enough to be individually good, the physician and the documentation specialist has to work well as a partnership. Better cooperation between the doctor and the documentation specialist = more RAF points = more money for the hospital = better donuts in the physician lounge.

April 13, 2017

My college freshman English professor told me: “You are not writing for yourself, you are writing for your reader. Always put the reader first.” It is a great message… and one that electronic medical records (EMRs) have made us totally forget. That professor would once a week have us critique an article by a particular reporter for the Cincinnati Enquirer – our job was to completely tear it apart from the perspective of the reader. If he could get a hold of a single progress note from our hospital’s electronic medical record, he would have a enough material for an entire semester.

In a previous post, I mentioned that there are fundamentally 3 reasons to have a progress note:

1. To communicate with other healthcare providers
2. To provide documentation for medial-legal purposes
3. To provide documentation for billing purposes

Electronic medical records make it really easy for us to document for billing but as a communication tool to other healthcare providers, they often fall woefully short. Our hospital uses the electronic medical record program, Epic. It is an incredibly powerful program that allows us to import all kinds of information into a progress note: lab test results, vital signs, past medical history, vaccination records, etc. As a physician, you can go wild with documentation – you can generate a 10-page note full of data just for an office visit note for a patient who comes in to get ear wax removed.

I’m on both the sending and the receiving end of electronic medical record progress notes. From other hospitals, I’ll get printed copies of notes mailed to me – pages and pages of data for a single office visit with a doctor who is co-managing the patient with me. From our own hospital, I’ll get notes from a colleague in a different specialty routed to my electronic medical record “Inbasket” and I’ll need to scroll through mounds of regurgitated data just to find the physician’s impression and plan.

But here’s the thing. If I’m treating the a person’s COPD, I don’t really need to know nor care about what their chloride level was in 2011 or the results of their last 6 normal EKGs. If I need that information, I can go to the lab or EKG section of the electronic medical record and I don’t need that information clogging up a progress note sent to me by another specialist seeing the patient for an unrelated problem.

The electronic medical record is a great documentation tool but we make it a poor communication tool.

Fear has taught us that more is better. If we include everything in the patient’s chart in our progress note, then surely we’ll get all of the right elements to withstand a Medicare billing audit. And shouldn’t we include every lab test the patient has had in the past 3 years just in case the person reading the note wants to see them? As a referring physician, I don’t really care about reading a consultant’s 11-point review of systems and re-statement of the patient’s family history since I already know this information and it is just a click away on the EMR if I need it. When it comes to really communicating in an EMR, less is usually more.

Don’t make the reader have to work to read your note.

There is a reason that we speak in sentences and that books are written using sentences. It is the most efficient way that we process the communications that are given to us. Tables and lists can help support the sentences but it takes a lot of time and brain energy to analyze tables and lists and in an EMR, most of them are just unnecessary fluff for the reader. When I get a communication from another doctor, what I really want to know is what their impression of the patient’s disease is and what they plan on doing about it. Sometimes that impression and plan is at the beginning of a long note of otherwise tabular documentation garbage, sometimes it is at the end, and sometimes it is in the middle – causing us to scroll up and down the notes trying to find out the information that we really want to know. The reader shouldn’t look at reading the progress note as a chore. The absolute best communications I get are from one of our surgeons who sends me a 1-paragraph letter saying what he thinks the patient’s problem is and what he is going to do about it. He communicates more in 2 sentences than most routed EMR notes communicate in 6 pages.

An inpatient progress note is often a communication to the outpatient physician.

My return outpatient visits are scheduled every 15 minutes. That means that when I see a patient in the office after a hospitalization, I have 15 minutes to review the record, talk to the patient, do an examination, order tests and medications, and complete my office note. I don’t have 7 or 8 minutes to spare to hunt through the recent inpatient chart to figure out what was going on with the patient and what I need to specifically follow up on. So I go to the last pulmonary consult note in the inpatient chart to see what pulmonary problem the patient was in with and what I need to be focusing on. If the patient needs a follow-up chest x-ray, or pulmonary function tests, or a decision about when to stop a pulmonary medication, I’m expecting that note to have that information. In this sense, the inpatient progress notes are not just a communication to the other physicians and practitioners seeing the patient in the hospital, they are also a communication with the outpatient physicians to insure a smooth transition from inpatient to outpatient care. Often, I’m both the pulmonary consultant in the hospital and the outpatient pulmonologist for a given patient and in this situation, my inpatient notes are notes to me and the nurse practitioner that I work with.

Don’t use a $25 word in a 25¢ sentence.

William F. Buckley was the conservative host of the TV show Firing Line and was famous for using 5 syllable words that he would pull from deep in the bowels of the English dictionary. He sounded extremely learned and intelligent but the average person couldn’t understand half of what he said. He used his extensive vocabulary like a weapon in political debates. That is great for entertainment but terrible for trying to communicate critical medical information to a wide audience of healthcare providers who will be reading your note. So don’t describe a person as macrosmatic, valetudinarian, or pauciloquent in an EMR note just because it showed up this morning on your “word of the day” app – no one else knows what it means any more than you did yesterday.

January 27, 2017

There are fundamentally 3 reasons to have a progress note:

1. To communicate with other healthcare providers
2. To provide documentation for medial-legal purposes
3. To provide documentation for billing purposes

In the 1980’s, communication with other healthcare providers reigned king. We marked up medical student H&Ps with red ink if they didn’t have perfect grammar and we carefully dictated referral letters and then edited them before sending them out. Nobody cared about billing documentation back then – it just wasn’t important. All of that changed on June 21, 1996, when the Office of the Inspector General announced the PATH audits – “Physicians At Teaching Hospitals”. Although designed to be a way to protect Medicare against billing fraud, the PATH audits turned into the medical billing equivalent of the Spanish Inquisition. Federal Inspectors would do probing chart reviews of physicians at academic medical centers and if they found charts that didn’t have the right documentation elements, they would swoop in and do a massive audit of all of the physicians, often resulting in fines of 10’s of millions of dollars.

It was easy for these investigators – Medicare had established billing rules and required that the each progress note contain sufficient elements to justify different levels of billing. So, for example, a given level of billing for a new patient visit had to have at least 3 symptoms, a past medical/social/family history, 9 different systems documented in a review of systems and at least 11 different body parts examined. If the inspectors (who were not physicians) did not find all of those elements, the physician had to pay back the money from that particular bill and was also susceptible to an additional fine for each progress note that didn’t pass muster.

Although there were examples of clear fraud, for example, a surgeon who billed surgical procedures in Minnesota but had credit card receipt documentation that he was in London, England at the time, most of the cases labeled as “fraud” were really just good doctors trying to take care of patients but not documenting every part of their physical exam or forgetting to list all of the patient’s previous surgeries in their H&Ps. There was also a dark side of the PATH audits because they could also be vindictively.

You see, if a person called the Inspector General’s whistleblower hotline and it resulted in an audit of a physician (or better yet, a large academic medical center group practice), then the whistleblower got to keep up to half of all of the fines that the government collected. You could become a multimillionaire simply by calling in the dogs of the Inspector General.

In the late 1990’s, I was the subject of such a vindictive investigation. We had recently cut the salary of some of the physicians in our group because of low productivity and I was in charge of the clinical/financial management of the group. That year, 3 of our physicians left and one particular physician left the University, harboring a lot of anger and resentment, mainly directed to me since I was perceived as the one who cut his salary. So, he called the Inspector General’s whistleblower hotline alleging that I had fraudulently billed millions of dollars to Medicare. Because of the enormous dollar amount alleged, the OIG descended on our hospital’s medical records department and pulled every single progress note, procedure note, and H&P I had written or co-signed over a 3-month period.

It took them months to comb through thousands of my notes and with each note, they had a scorecard that they would check whether or not I had enough review of systems documented and enough body part examinations documented. It must have cost the OIG a small fortune to send investigators to review all of these notes. We hired an attorney to represent me through this process because of the fear that if I didn’t have the right documentation, it could open the door to a dreaded PATH audit that could essentially wipe-out the physician faculty ranks at Ohio State University. After the completion of the audit, here is what they found:

1. I had over-billed by one level about 5 times (I had to pay back the difference – total was less than $100)
2. I had under-billed by one or two levels about 25 times (total was about $2,000 but they don’t give you any money back in this situation)
3. I had a few notes that I had written when billing ventilator management charges (used by pulmonologists rather than the more documentation-intensive return visit charges). Unfortunately, in addition to my notes, my medical students also had notes in the chart that referred to the ventilator settings and ventilator weaning. Because Medicare classifies ventilator management as a procedure and because any procedure done by a medical student, even with full supervision by the attending physicians, cannot be billed to Medicare, they asked for all of the money back for these notes – total about $200. Although I had done all of the actual ventilator analysis and written all of the orders, since the students also documented the ventilator settings, they said that the “procedure” of ventilator management involved medical students so I couldn’t bill it.
4. I had come into the hospital one night to see a patient with acute respiratory failure in the ICU – I intubated her, put a central line in her, and did a bronchoscopy. In addition to the procedures, I also billed a critical care charge – for this charge, you have to document that you spent at least 31 minutes providing critical care services independent of any procedures. I had my documentation right there – 11:40 PM to 12:25 AM and I had each procedure note timed with a different time either before or after the critical care times. However, the auditors stated that since the time crossed midnight, 20 minutes of the time had to be accounted to one calendar day and 25 minutes to the next calendar day and since neither of the days’ time was >31 minutes, I couldn’t bill any critical care charges and in fact, was not allowed to bill anything. I had to give back $175.

Before this, I had been a documentation freak so my notes were actually very well-documented and so the amount I had to pay back to Medicare was truly trivial. The OIG spent many times that much in salary, hotels, food, and airfare for the inspectors that they sent to Columbus. My ex-partner got nothing as a “whistle-blower” and our University did not get a resultant PATH audit.

Our electronic medical records now make it simple to ensure that each note has the required number of body parts examined and the correct minimum number of systems documented to be reviewed in the review of systems. The PATH audits have gone away because there just isn’t any money in it for the OIG anymore. However, the legacy of the PATH audits is the topic of my next post – the cluttering of physician progress notes with excess documentation by doctors who do electronic medical record documentation overkill to avoid even a chance of not having enough documentation to support a Medicare bill in the event of an audit.

January 23, 2016