In this episode of our podcast, Compliance Conversations, CJ Wolf interviews board-certified internist and cardiologist, Jim Dunnick. Wolf and Dunnick tackle documentation, what to do, what not to do, and what you definitely didn’t learn in medical school. Wolf is a compliance expert who found a passion for the compliance side of things after graduation. Dunnick is not only a physician with years of practice experience, he’s also a full-time consultant who educates physicians on coding and documentation best practices. Documentation dream team, if we’ve ever seen one. We’re swooning.
In this detailed, thought-provoking session, Dunnick and Wolf dive deep into compliance, coding, and audit risks. They explain how to use EHRs effectively and efficiently and why you should be weary of copy and pasting. And thoroughly cover documentation best practices that every physician should know.
Tune in to this Podcast, A Physician Explains Documentation Best Practices, to learn how to document correctly, ways to reduce audit risk exposure, and get the scoop on what you didn’t learn in medical school (but definitely need to know now).
Easily listen on iTunes or Soundcloud, during your commute or on your lunch break. Enjoy!
Episode 3 Transcript
CJ Wolf: Okay, welcome back to the show everybody. Today we have a wonderful guest Dr. James Dunnick and we have some really good topics to talk about today. Dr. Dunnick is board certified internist as well as cardiologist and he now is working full time as a consultant with the Dunnick group and he spends a lot of time educating physicians and coders and I thought it would really be interesting to hear a physician whose practice for many many years and who now is trying to help other physicians and practices and coders and even hospitals trying to educate doctors on documentation best practices. So welcome to the show Dr. Dunnick.
Dr. Dunnick: Well thank you I am glad to be here.
CJ Wolf: I appreciate your time and your expertise and I know you’re in a pretty unique position being both a board certified physician with years of medical practice experience but also somebody who I guess a little more recently who has focused on coding and documentation and auditing experience expertise. if we could just maybe start off with…. if you had a room for full of doctors what’s the best advice you could give doctors today as it relates specifically to their documentation practices?
Dr. Dunnick: I think that we all need to understand that this isn’t a function to argue if you did a good job putting in the pacemaker or caring for the thyroid disease, it’s not a function of how well you practice its becoming or a marker of how well you document. Unfortunately, if we don’t document correctly then we run the risk of delays and denials and now that the audit trail has been lengthened from 3 years to 6 years, payers are allowed to go back six years. Now that that’s the case, we just have this exposure, one of the issues is we were never really taught how to do this very well in medical schools. I think you could argue that perhaps it’s not necessary if we know how to do these things but we do have to do it this way. So it’s really important that you understand how an E&M evaluation and management how an E&M note is constructed. Auditors are going to tear this apart, so let’s just build it like she wants to see it; let’s reduce our audit risk exposure.
CJ Wolf: That’s a really good point you know, I also went to medical school I didn’t practice afterwards though and kind of got into the compliance and educating physicians and I think you and I have talked other times about how we would love to be able to see in a medical school curriculum best practices and documentation - just like how parents are teaching children the routine of brushing teeth and tying their shoes. You kind of learn those habits young and doctors are learning to document a physical exam and know history and they are learning that from a clinical perspective. It would be nice to be able to try to teach them at that moment. Okay, this is what you’re doing for clinical care but in the real world you’re also faced with auditors and you’re also faced with some of these other pressures that unfortunately might not be directed at clinical care. But, like you said, this is what folks are going to be looking at when they are reviewing records. Have you done much training with younger doctors? I have done some in residency training doctors in residencies are there any thoughts on that?
Dr. Dunnick: I think that would be a great thing to do: teach you how to do things correctly today, say that you have to do it. I think I can understand why medical schools don’t do that. I had the opportunity about two years ago to talk to a president in the College of Radiology and I asked him about it and he said “we teach medicine we don’t teach you how to staff your office or negotiate your loan to build your new building, we teach medicine.” So I understand that from their point of view, the problem is if they are not going to teach it, then it falls on the shoulders of the individual position and the hospital to do this education. One of the thing that auditors look at heavily is the medical necessity and if I haven’t done a good job of defending why I did whatever I did. For example, it is possible for the payer to not only deny the physician fee but he could turn around and deny the facility fee, the anesthesiologist fee, the family doctor pre op clearance fee, all of this is then in jeopardy simply because no one ever took the time to learn word how to properly construct their notes, data-point problems and the medical necessities-the table of risks-and all of these things an auditor is going to look at.
CJ Wolf: Yeah you know I am glad you brought up the point of medical necessity and it’s not just in E&M evaluations and management it’s also in procedures and a little while back I gave a webinar and I included a case of a cardiologist in Tennessee and it was alleged, whistleblower in this case was actually another physician he was the medical director over the cardiology department in the hospital and the physician that he was blowing the whistle against his concern was that that this physician was kind of exaggerating the severity of blockage in the coronary arteries for example and it came down to the medical record read just fine but if you look at the images the cardiology image did not jive with what was in the in the medical record and so this medical director blew the whistle the physician ended up paying back some money but just as you just said because that physician is doing these procedures in hospital, the hospital is at risk for losing a lot of money because the government will say you know that service was not medically necessary not just for the doctor but it wasn’t medically necessary for the hospital either and they had to return a lot of money. Have you dealt with cases or physicians in your consulting or in your experience where you of been the one who have tried to decide and help entities determine whether that procedure or that service was medically necessary and how do you go about doing that if you have been involved in that?
Dr. Dunnick: Yes I have done that and it’s all again about documentation know the case you’re describing sounds a little bit more criminal to me, if someone it is describing a 30% lesion has a 85% lesion and then goes ahead and perform angioplasty that sounds a little bit more as I say criminal but what I deal with predominantly are just people who makes errors in documentation, I was with a cardiologist a few days ago who had said in his history of present illness (HPI) a patient presents with stable chest pain 2 to 3 times in a week and when you get down to impression plan it says left heart catheterization today so you see how a review I would look at that it doesn’t make any sense what really happened of course was ever two weeks he has been seen the patient in his office and after doubling the medicine the chest pain is still occurring 2 to 3 times a week and in fact he neglected to mention he had five minutes of rest pain last night so you wants to do heart catheterization today, so when you talk to the physician it becomes very good judgment call and you completely understand everything, he just didn’t document enough so I teach physicians or suggest to them when we are talking about medical decision-making what you and I used to call impression plan it is no call medical decision-making, this is where I want you to be worthy, this is where I wanted to explain to the auditor how hard it is to do what we do every day the procedure notes the E&M notes they are just such strict rules in what to put where and who may put what where and a lot of times physicians look at electronic health records and as though this is an efficient way to do this but in Medicare’s eyes doing it that way is fraud so there are just a lot of aspects that goes into protecting the money you have earned and then as you point out the fallout to other people if you have done something wrong the fallout to other people can be other providers on your team.
CJ Wolf: I like what you said about when you’re teaching doctors about medical decision, documenting the medical decision teaching portion that you want them to be wordy. I remember training doctors as well and what I often would say is: look, you spent all of this time in medical school and training in residency and then years of practice and to you all of this stuff is happening in your head pretty quickly and because you have seen this case over and over again you kind of already know what the conclusion is. But I always tell them you are the artist you get to paint the picture and you can paint the picture with stick figures or you can paint the picture with a lot of details that demonstrates “oh! you as the physician had to go through this clinical decision making in your mind that upends invisibly but try to get that invisible thought process down on paper and that really can demonstrate all that you were thinking,” and that’s kind of hard for docs to do.
Dr. Dunnick: It really is especially when we don’t understand the rules nobody ever taught us this and we don’t realize what an auditor is going to do.
CJ Wolf: Yeah
Dr. Dunnick: An example of the confusion might be if you have a note and it says “chief complaint of chest pains” and your history of present illness starts with chest pains 2 years ago he had bypass surgery. But unfortunately he hasn’t quit smoking and he is still 50lbs overweight. Well when an auditor looks at that, she looks at it differently than you and I do. I understand chest pain, the guy had bypass surgery and that’s very important. And I understand why you put it there I understand why you put the tobacco and the weight there, but for an auditor, the tobacco slides down the social history, the bypass surgery slides down the past medical history. So when I’m adding up your points in the HPI you’re only left with chest pain and in fact you lose the chest pain because that was counted as your chief complaint of chest pain. So you’re sitting there with an HPI which is a zero value or the same value as if you dictated absolutely nothing.
CJ Wolf: So what would you recommend to correct that one? So that’s a great example what could somebody add to that, appropriately add to that so that they don’t miss those points so to speak?
Dr. Dunnick: There are eight elements that makes up the HPI and depending on how many of those you address your plain level will go up appropriately so for example if you are in the office your choices are a 99-11 up to a 99-215 if you are an established patient, if you are in the hospital doing a doing a new HMP it might be a 99 201 to 205 but again the level that you can claim is a function in the HPI of how many elements you use then in the physical exam it’s a functional of that and in the medical decision making that’s where the problem points and the data points come into play. so there actually are ways you can learn this and it’s not quite as complicated as it first seems but we have come full circle back to the fact that we do have to learn it and it falls on the shoulders usually of the hospital to train their physicians because the hospital has so much at stake if this is done poorly.
CJ Wolf: Yea good point, you mentioned a few minutes ago electronic health records and I want to maybe shift gears a little bit and go to that topic because electronic health records are becoming more and more prominent and I know you have worked a great deal in educating physicians about best practices for electronic health records. What would you say are some of the biggest mistakes or the risks that physicians or others tend to make in electronic health record and maybe you could also touch a little bit on this copy and paste phrase that we hear all the time?
Dr. Dunnick: Sure I think I might list two things as perhaps being the most common problems and I agree with you that one is called cloning whether we described that as copy forward, copy or paste super clicking when you are clicking for example… a revue of systems Did you really ask all of those questions or did you just click all of those boxes? The same thing with the physical exam did you really do all of those aspects of the physical exam or did you just click those boxes? So that’s called super clicking. one of the problem with copy forward copy paste and I think this makes sense from Medicare’s point of view or from any payers point of view, if I see you in March and I did a past medical history review of systems I did those sort of things and then and then I see you again in June well if I just bring forward the old past medical history, the old review of systems from Medicare’s point of view I paid you for that in March you may not bring the same thing forward into June and expect me to pay you for that again, so you understand how it sort of makes sense from Medicare’s point of view that it would be double payment for the same service. so that copy forward here is a problem many of the electronic health records will automatically populate your hospital notes hospital are very important part of our service when they bring of the progress…………[15:45.8] For today and I’m going to type in it often has today’s laboratory value already populated, well from a problem point and data point of view once you have reviewed the x-rays in the lab you get credit for that but when the machine have just dropped that on your note there is no documentation that you looked at it so there are certain ways to establish in the auditors mind that you did indeed you are really aware of the follow-up chest x-ray the follow-up CBC whatever test it is that we are talking about and it’s just defending yourself and defending your documentation so that again you can pass the scrutiny of an auditor.
CJ Wolf: It’s as simple as saying “so I reviewed today’s labs or I reviewed the labs and the records that showed up today”, making some sort of affirmative comment and is that bringing it in.
Dr. Dunnick: Yes, and give me an answer I reviewed today’s hemoglobin and it is stable at 10.1 I reviewed today’s chest x-rays and it appears to be having an improvement. So we want to make a comment that clearly shows the auditor that you did indeed see the lab because you’re verbalizing the result of the lab.
CJ Wolf: Good point.
Dr. Dunnick: Second really common mistake, and I understand I don’t want to really call this laziness, I understand we have a lot of support personnel that help us do a lot of things and sometimes a physician will ask the support personnel to enter in some of the notes, but there are again strict rules as to what has to be entered into the note by the billing provider and what may be entered into by ancillary services and we make that mistake a great deal. Again not out of trying to do something inappropriately but just that we didn’t realize that there were those strict rules. So it comes down to education for us and as a number of auditors have been increased and I just had an in email about a month ago from sort of a watchdog group or something the Medicare audits were up 936% in 2015 and as these things become more and more because it’s a lucrative field for the payers. They can get money back and of course payers are looking for fellows especially like the cardiologist that you describe that they may be on purpose trying to gain more money than they really deserve. And while the payers are looking for those folks they are finding an incredible number of us who just made a mistake, because we didn’t realize what all of the rules were, we didn’t realize that we were doing some things that payers don’t want us to do.
CJ Wolf: On the electronic health records topic: I’ve heard a lot of doctors tell me when I go out and try to teach and educate they will say “what’s the point of having electronic health records record if it’s not going to be easier for me?” So I kind of feel for them and I get what they are saying you know, these electronic systems are supposed to make things easier. So how what is different wit like with the paper record and now let’s say they are using electronic health record how can they use it to make things easier in using that functionality without getting in trouble of these cloning and that sort of thing any other thoughts on that particular issue?
Dr. Dunnick: When I get asked to go to hospitals, as you can imagine, and any number of the different medical record companies out there, I always tell them all medical records have pluses and minuses, all of the electronic systems have their good on their bad. So with this particular one let me show you how to take advantage of the things that it does really well and also let me show you how to minimize the things that it does really poorly. Let’s focus on what you actually have to enter, let’s focus on how you can jump around a little bit within the electrical/electronic chart so that you’re making as few clicks as possible. I completely understand the pushback from the physicians because they are slowing, it does improve hand writing errors and it does make it very nice when I’m sitting in the emergency room and I can bring up my office chart in seconds so I can see my partner’s old notes or the old hard copy - there are really nice features about electronic health records. For me, I get audited charts in Nebraska from my home, and I can just pull them up on the internet.
CJ Wolf: Right.
Dr. Dunnick: But they are absolutely slowing limitations to it from the standpoint of productivity, so it’s important to understand where you can take a shortcut or you can take advantage of one of the rules that allows you to do something without trying to take advantage of a rule that seems like it ought to be there but it turns out it’s not there.
CJ Wolf: Yeah like I remember as you were talking a doctor came to my mind that I trained years and years ago, he was a internist but he specializing diabetes and so the majority of the patients that he saw kind of followed the same type of history physical exam and he you know he kind of did the same thing so he created a template that for him was useful and then the details about that particular patient might be slightly different but it still followed that template and that saved him a lot of time is that something that you know you seen and that’s okay versus what are some of things to watch out for if a doctor develops his own template for a given type of patient population.
Dr. Dunnick: Well I would think several comments about that. First, it’s impressive to me how many people have designed a template that isn’t audit consistent it’s not the same template that an auditor is going to use, so I would design a template that matches up with the auditor for example the auditor is going to tear it apart but still looks like she wants to see it but they just want to check off their boxes and as soon as you develop the reputation if you’re doing a really good job then it’s going to have decreased scrutiny and there certainly is some amount of automatic and the normal routine scrutiny but you don’t want to be the person that it looks like you’re doing a lot of things wrong. So it’s important to have your template be consistent with current auditing processes. The other aspect about templates depends on exactly what we mean by “templates” because you want to absolutely stay away from the copy-forward or the copy paste type things. The payers are very aware of that and they know how to hunt for it. Normal humans, we just wouldn’t use exactly the same phrase day-in-and-day-out, so it really can be shown so the burden of proof sort of falls on us.
CJ Wolf: Yeah.
Dr. Dunnick: Because it shows that we didn’t do something correct and even if you bring a guy like me or somebody else in to try to defend you during the audit and even if I win is taking a year and you end up getting $.70 on the dollar a year from now and you have to pay all the man-hours to defend the audit to put your stuff together. So I think the best is just doing it correct at type zero that just means having someone show you all of the aspects of ICD 10 and medical necessity. When I teach ICD 10 it’s really is logical really don’t worry about the fact that people will always frighten you and say that there’s 150,000 total codes don’t worry about that all you really have to understand are there a couple off fundamental rules like code 1st code also and understand that you can’t say stroke we have to talk about right versus left, we have to talk about which artery is involved we just have to be more specific than we are used to dictating but again once you show. I actually use slides they are snapshots right out of the ICD 10 book and say look years hypertension but look what the coder has to pick from so just give her the words that she needs to select the correct code I always say put what she wants to see where she wants to see it...
CJ Wolf: Yeah.
Dr. Dunnick: Everyone feels that the coder turned in the bill well if the coder is messes up that’s the coders fault and that’s not true I agree the: the code on the billing department probably turn in the bill but it went in under your name it went in under your tax ID and the payer comes back as the person who charge the bill the person who receives the money that’s who the payers come after. So maybe it wasn’t even your error you had no idea what claim level they were turning in but if they are wrong you are the one who has to defend that defend why you should have that money.
CJ Wolf: Excellent, excellent conversation we are coming up to the end now here of our time together I would love to have you back at some point because I think we could pick up on some of these other topics and things that you have discussed. I wanted to thank you for your expertise and for your time and I would like to thank everybody who’s have listened into our episode today and until next time we will look forward to having you back thank you.
Dr. Dunnick: Thank you very much, I enjoyed being here.