Episode 133:
Make It Make Sense: Medical Decision Making Documentation That Holds Up

Episode Chapters / Timestamps 

00:00 – Welcome & Introduction
CJ Wolf introduces the episode and welcomes Amanda Reikowsky to discuss medical decision making.

02:29 – “Make It Make Sense”: Reframing Documentation
Amanda explains why documentation should reflect clinical reasoning—not just completed tasks.

05:56 – Common MDM Documentation Mistakes
A discussion of missing rationale, unlinked diagnoses and plans, and the dangers of copy-forward notes.

08:05 – Patient-Specific Risk: What Auditors Look For
Examples including COPD, diabetes, kidney disease, and how risk must be individualized.

11:37 – Additional Risk Scenarios & Clinical Context
How contrast imaging, pregnancy, and comorbidities influence complexity.

15:08 – E/M Guideline Changes & Outdated Templates
Why history and exam no longer drive leveling—and how templates haven’t always caught up.

18:11 – Over-Documentation & Clinical Trust
How note bloat affects patient care and physician confidence in the medical record.

20:33 – One Practical Tip Providers Can Apply Tomorrow
Write your assessment and plan like you’re handing off care to another clinician.

22:29 – Legal Exposure & Documentation Defensibility
Lessons from liability case reviews and why documentation must stand on its own.

CJ Wolf: 00:00
Hello everyone. Welcome to another episode of Compliance Conversations. I'm CJ Wolf with Healthicity. And today's guest isAmanda Reikowsky. Amanda, welcome to the show.

Amanda Reikowsky: 00:13
Thank you so much for having me.

CJ Wolf: 00:15
Yeah, I'm so grateful that you're willing to take some time and share with us and all the listeners. We're going to talk about a really cool topic when it comes to kind of coding and auditing called medical decision making. But before we get there, we'd want to hear a little bit about you, Amanda. Tell us a little bit about yourself, if whatever you want to share.

Amanda Reikowsky: 00:35
Yeah, sure. So I have been in the industry for 13, a little over 13 years now. I'm currently a supervisor for a coding quality audit and education team for Hackensack Meridian Health in New Jersey. But I am also the founder of CodeWise Solutions LLC, where I kind of work as an independent consultant. Primary focus is with medical cost projections or life care plan analysis and liability, personal injury cases. But I also do coding audits, education, speaking engagements. Spoke at HealthCon last year, speaking again this year, did some Blue Cross Blue Shield of Kansas provider seminars and things. So a lot of different projects, including this one. But yeah, I have you know far too many letters after my name, but um for four certifications through AAPC and then uh a certification through ICHCC, the International Commission on Healthcare certification. Um, and I've been working with their groups on education for their certified, you know, professionals there. And um, I guess outside of work, I, you know, mom, three kids, French bulldog breeder, and when I pretend that I have free time, um majority of the time I'm reading or preparing for another presentation coming up.

CJ Wolf: 02:03
Awesome. Well, you are a busy woman, and we are again grateful that you're willing to take a little bit of time here. Um, and uh, if you're comfortable, we'll include your contact information in the show notes because if any listeners you know want to engage you for your services, uh they can reach out to you.

Amanda Reikowsky: 02:20
So I appreciate that. Thank you.

CJ Wolf: 02:23
Absolutely. So I loved it when we were kind of brainstorming on a topic and we talked about medical decision making. You said, Yeah, yeah, I have a session that I call Make It Make Sense. And so I thought that was a cool way to kind of introduce medical decision making talk. So tell us why you call it that and and what what you think about that title.

Amanda Reikowsky: 02:45
Yeah, so make it make sense really is about kind of shifting how we think about documentation. So, you know, for years, providers are taught to document to prove that they worked. And there's there's all like checking all these boxes and filling this template, and unfortunately, copy and paste, you know, to make sure everything is there. And now documentation should be how providers think clinically. You know, why did you order that test, or what were the what were the rule out conditions, you know, what are you considering? You know, what why did you choose this treatment over another? Um, so it's really, I think, you know, we've heard this a lot, but about the note telling a story, not just what happened, but why it happened. You know, that's where the real value is. You know, anyone can document a list or make, you know, check marks to say this and this and this were done, but not everyone can document that reasoning behind it. So really the it's not to, or my session is never to go through and define and explain all the different levels of medical decision making and how to get there. It's really about what documentation is needed to support any particular, you know, condition being treated or level of service and just again make it make sense.

CJ Wolf: 04:06
Yeah, I love that. That's I think that encapsulates what we're trying to do. And uh, as you were mentioning that describing it, uh, I don't know if you or any of our listeners watched the medical show called The Pit. Um, I I think it's on Macs or something. Anyway, uh it's kind of a new medical show, and and the pit is a ER department in in the University of Pittsburgh, I believe. And um, I was watching one of the episodes where they had a medical student and the attending was looking at the medical student documenting, and I was shocked that the on this popular TV show, they said, Are you documenting your medical decision making? And the the student said, Are you telling me to pad my note? And the doctor says, No, all I'm saying is you are cognitively thinking through all these things, put them down there. That's not padding your note, that's helping the reader see what your thinking was. And so I thought, oh my gosh, a popular TV show is talking about medical coding and documentation. Who would have thought it?

Amanda Reikowsky: 05:09
It's amazing. I don't recall the the show, but there was like an administrator coming around the round. I don't know if it was Gray's Anatomy or something else, but it was talking about this new process that they're calling, you know, upcoding. We're gonna be in there literally, and I'm like, please stop, turn it off, make it go away. Oh, it was it was interesting.

CJ Wolf: 05:31
Yeah, it's like, no, don't talk about that. This is my downtime. I don't want to be at work.

Amanda Reikowsky: 05:35
I want to Right now, I'm auditing a TV show.

CJ Wolf: 05:38
So you mentioned at the beginning that you, you know, you you have clients yourself, you're doing a lot of uh, you know, private consulting and audits and those sorts of things. So you're probably seeing a lot of common mistakes. Um, and so could do you mind sharing what some of the most common medical decision making uh documentation mistakes that you see providers uh making?

Amanda Reikowsky: 06:01
Yeah, so uh a lot of things sometimes I see is that that lack of the clinical reason, like the justification behind placing orders. Um, and sometimes I'll just see sometimes a list of diagnoses and then a paragraph after. And there's no link to what particular plan uh is being contributed to any one condition. So, how can we support each of these as being managed if none of it is linked to the rationale, you know, that reason why? Um, and then of course, copy and paste or some it's not we're not it's forward and edit. We're not gonna say copy, it's a bad word, but it is what it is, right? When your plan looks exactly the same for six months, uh there's a problem. Uh we I had a provider whose notes looked identical for 17 days in a row in an inpatient stay, no difference. Some have the the uh they're kind enough to add a period at the end of, oh look, I I I'm updating it, right?

CJ Wolf: 07:03
This is not.

Amanda Reikowsky: 07:06
Um, you know, and so that's that's an issue. And then the the other one is really just saying something happened without qualifying the con like I this is medical decision making. So you can say all you want, but how did it affect your medical decision making? So I'm specifically talking about things like you know, discuss with primary team or you know, reviewed the reviewed the MRI. Okay, and then what? Where's the rest, right? Like, like okay, talked to infectious disease, and based on though that discussion, we're gonna change the antibiotic. Perfect. We now have the clinical judgment how that medical decision making was affected. And so it's just really a lot of I did all of this work, but no real how did it affect the medical decision making?

CJ Wolf: 07:60
Yeah, such a good, a good response. I actually was just talking to a client myself about um uh COPD, so chronic obstructive pulmonary disease. Um, I come from a clinical background, so a lot of the the language that they were reading to me made a lot of sense. The doctor was stating, um, because the coder was asking me, is could this be, you know, um a problem that could be a risk to life or bodily function? I said, Well, it depends. You know, that might answer. She said, so she started reading me the language, and I said, Well, because this was a pain management doctor. Patients with COPD, um, most of us, what drives us in respiratory effort is the amount of CO2 in our blood. But patients who have COPD, their body adjusts to that, and what drives their respiration is low oxygen. And so the the doctor was actually doing exactly what you said, wrote out, look, I'm not treating the COPD, I'm treating this patient's pain. But because the patient has COPD, their respiratory drive is significantly affected by these opioids that I'm giving the patient. And so this is a little bit higher risk in this type of patient compared to a patient that doesn't have COPD. So they kind of wrote all that out. And I thought, you know, that's a really good explanation of kind of what you said, make it make sense. Why do you consider this patient higher risk when the average person taking opioids it might not be? So I don't know. What do you that? So does that scenario, do you agree with that? Or does that what you mean by that?

Amanda Reikowsky: 09:42
Absolutely, because when I when I do this session and I get to this part on risk, um, and I say, you know, it's you know, if a procedure or treatment option, you know, with or without patient or procedure risk factors, I always say they're not talking about the risk factors like pain, bleeding, bruising, infection, all the way up to including death. It's like inherent with every procedure, right? But but what makes this more of a risk for this patient versus someone else? A common example I use um like in orthopedics with steroid injections. Well, if that patient's a diabetic, now we have a little bit of an increased risk because it's gonna affect their blood sugars and that sort of thing. But if you're just saying, oh, we're gonna do you know joint injection, kenalog or dexomethosome, whatever, and leave it at that, you're looking at minor procedure, no identified risk factors. You can even say risks and benefits discussed, that means nothing. I mean, it means nothing to the patient, right? But as far as if there's risk factors or not, that doesn't give us enough to support. I mean, I could see they have diabetes in their past medical history. Like I can see they are also on metformin or insulin, or and I'm like, this is gonna be a problem, but they didn't document it. So that's another one where it's like just just a little bit more, and you've oh you know, increase this to moderate, you know?

CJ Wolf: 11:07
Yes.

Amanda Reikowsky: 11:08
Yeah, exactly.

CJ Wolf: 11:10
That's a great, great example. Um, I want to talk about some more examples, but we're gonna take a really quick break and we'll be right back, everyone. So so stay with us. Welcome back from the break. Uh, we're talking to Amanda about medical decision making, and I love the way she put it, make it make sense. And we were talking about some of these examples. Um, and you you were sharing that example about a joint injection and and diabetes. Here's one that I see a lot. Tell me what your thoughts are on this. Maybe you see it too. A lot of patients uh have kidney um uh disease, right? And what is a normal procedure for me, somebody who doesn't have kidney disease. So, for example, if I'm getting a CT scan with contrast, um, it might not be such a big risk for me, but somebody who has a really, really bad um GFR, you know, the glomerular filtration rate, they could be at signific could be at more risk because of their kidney conditions. I I think that's a good example of trying to show that look, this procedure carries some risks with it that's not normal for everyone else. Do you agree with that one?

Amanda Reikowsky: 12:20
Yeah, and I think it applies to a lot of different testing or treatment options or you know, we smokers, diabetics that pose healing risks. So that should be a consideration for biopsies, even, you know, um, any sort of test that's that's that's gonna be invasive in any way. And by invasive, I mean you're gonna puncture the skin in order to do it. And then, you know, very similarly uh with any kind of uh a testing option for or medication treatment option for a pregnant patient, you know, or um, you know, uh I sort of say like over-the-counter medications when they already have a risk for liver issues or or something. So especially with kidneys that go through a whole lot of filtration of of our blood and everything, it's it's most anything with a kidney condition is gonna have that increased risk. Unfortunately, documentation doesn't always match that, you know.

CJ Wolf: 13:19
Exactly. Yeah, and when I'm teaching docs, I'm like, you I know you're thinking about this clinically, but you're so fast at it that you don't think of it as work. And so I just try to encourage them. Look, I know you thought about it, and if you did, put it down because that really helps make it make sense.

Amanda Reikowsky: 13:36
I I usually go over, you know, the the various treatment sections of the note and and I get to the assessment and plan, and some people look at me a little bit funny, but I literally will say something along the lines of like you should be treating this like your journal, like your diary. Like, like dear EMR, I saw Mary Jones today. She was looking much better than yesterday, but she's still not where we need her to be. And that's because you know, she's still struggling with abdominal pain. So, you know what? We're gonna follow up on those culture results from her UA. And actually, I talked to ID Dr. X, and he said we should maybe consider this medication until the culture and sensitivity comes back, and then we're gonna change it. So, based on that, I'm gonna order a follow-up UA, a follow-up culture, and we're gonna check back in with Mary, love always Dr. Me. You know, like just literally start that like, I thought about this, and then I was like, no, like get because all of that counts. And if if they're thinking, I'm gonna go with this, I can't go with this treatment option because it's not an option for them because XYZ, so we're gonna have to switch it because of that. They don't document that they think it, but they don't often document it, and that documentation would support that increased risk that's involved.

CJ Wolf: 14:52
Yeah, another great, another great example. Um, you mentioned at the beginning, you've been doing this for over 13 years, and I'm I'm scared to say I I've been doing it for over 26 years. So you and I both, and a lot of our listeners, have seen the change in the guidelines, right? So, you know, 10 years ago, we were telling doctors make sure you get all your review of systems, make sure you get your past family social history, because it mattered for EM, but it doesn't, those are important clinically, but the EM level is not selected off of that. So, how, in your opinion, how has the change in the EM guidelines shifted what really matters in documentation for coding purposes?

Amanda Reikowsky: 15:32
Yeah, so and that's one of the unfortunate things is that not a lot of the providers are following along. Like if there was one good thing the government has ever done for healthcare providers, is let them decide what's important in the history in the exam, you know, and and I could I consider it a trade-off, right? We are no longer putting ridiculous amounts of information in the history in the exam just to meet certain criteria. But now that trade-off is no more documenting so much up here. We need your your bulk of the documentation down in the assessment plan. And and um what I'm seeing right now is outdated templates that are still kind of forcing boxes to be checked with past family social. Um, I love it when I'm looking at a chart for a newborn baby and it says social history, never married, never a smoker.

Amanda Reikowsky: 16:26
Great.

Amanda Reikowsky: 16:27
Wow, good. I'm glad I mean accurate, probably, but what what how does that benefit the the the care at all? It really doesn't. Um, same with a you know, 85-year-old woman presenting for glaucoma and they're giving me an LMP date in her past medical history. Probably not relevant. And and and it's not just the history, it's the exam too, right? Sometimes we see these these full exams that are probably not uh relevant. And you know, of course, you should have an exam if the patient's coming in with a physical problem, and even with maybe coming in for depression and anxiety, you still have mood and affect and general appearance and things, but probably gonna start asking questions if I'm seeing breast exams on all your patients. Like, you know what I mean? Like it some of these things it doesn't just whatever makes sense to the presenting problem, put it there, and and that's it. Like, but it's those templates, it's these templates that have existed from the beginning of time and they don't like change. Um but this is really a good one. It's a really good change for our our clinical providers, and they should embrace it a little bit more, yes. Uh, so that you know, they they don't they're only really documenting what's what's necessary.

CJ Wolf: 17:48
Yeah. Well, and you know, you kind of alluded to it that there's you when you were talking about copy paste or pull forward and edit, however we want to say it, often brings a lot of over-documenting. So do you see you probably see that, and why do you think that's true for some providers that they're kind of over-documenting, if you will?

Amanda Reikowsky: 18:07
Because they think they still think that that's what's needed in order to bill for the services. They're not even, they're not understanding that it's it's not required anymore. I think I said something about the review of systems, and I'm like, don't don't even include it because it's being included and it's conflicting with your HPI because you guys aren't paying any attention. And and so I said, just get rid of it because you don't need it. No, you don't need it. I don't need it. Like, all like you can you don't have to have a formal review of systems. I always say you should maybe do a review of systems when it's a new patient or an established patient with a new problem. You might want to run through that kind of list, but it doesn't have to be in a review of systems section. It could be in your HPI, reviewed symptoms with patient, and they have this, this, and this, but negative for this and this. Make it a list. That's fine, but don't just throw it in there because it's part of the template, you know?

CJ Wolf: 19:03
It's not yeah, so true. You know, I uh another hat that I wear is I teach in a patient safety uh leadership master's degree program. And so we're addressing medical documentation not from a coding perspective, but just from a clinical care perspective. And there's a lot of research and in the literature that demonstrates that a lot of physicians don't trust the notes anymore. And it's becoming too difficult to sift through a four-page note to get one little piece of information that really is pertinent, and all the rest is superfluous, and it's slowing down patient care. Um, and so I sometimes combine my kind of coding advice with, you know, also just think of this, Doc. You know, another doc's going to read your note tomorrow or in a week or in a year. You don't want them sifting through pages and pages, like be pertinent, right? Like you can say their full history is on page, you know, one from a year ago. I'm going to talk about pertinence today. And so I also don't like this over-documenting, and I I sometimes try to take that from a quality of care standpoint, not just coding too.

Amanda Reikowsky: 20:16
Yeah, absolutely. Absolutely.

CJ Wolf: 20:18
Yeah, we're we're I want to ask you one more question because we're getting kind of close to the end. Um, it, you know, if you could give providers one piece of advice, right, to improve their documentation tomorrow, what would it be? Because sometimes it's overwhelming to hear all of these rules. So let's start small, let's just do incremental improvement. What's your one piece of advice for today?

Amanda Reikowsky: 20:42
Write your assessment and plan, your note, like you are explaining your decisions to another physician. Like you are passing off care from one shift to another, just like you maybe dictating out loud, why did you order that test? Why are you choosing that medication? What made you change the plan? If there were things that happened, I've got these things pending, and this is kind of what we're we're working towards. This is what we're thinking. And so if you were like like nurses at Shift Change or are you transferring to another provider that's taking over for you at the end of shift, document like you are having that discussion with them, because if you're not having that discussion, your note is that discussion for them.

CJ Wolf: 21:29
Yeah, such a good point, you know, and and even, you know, um, yes, explain it for other doctors, but sometimes doctors see certain language and they kind of know what the other doctor is saying. So I we might even say something like, you know, write it like you're explaining that to a medical student, right? Or or a medical resident who has a pretty good level of understanding, but might just be missing that last little medical decision making rationale that you as an experience. Experience physician have, right? And I love I love the way that you said that because that's a good way to think about it is to think I need to explain this to somebody who might not be thinking exactly the same way as I am, but you know, maybe they've got 50% of what I'm thinking. Because, you know, a lot of the a lot of the coders and reviewers, they they pick up on this stuff and they they kind of know already, right? Some of those things. So I love the way that you said that.

Amanda Reikowsky: 22:26
Yeah, yeah, absolutely. And and they always talk about well, you know, I I'm not I'm documenting for patient care, or I'm documenting for this and whatnot. But if you remember my consulting, I'm doing a lot of personal injury liability case reviews, and I'm reviewing a lot of providers' documentations from across the country. And I'm seeing some very concerning documentation practices where especially after they've received the request for documentation from legal attorneys, now it's cover your butt because they realize they're lacking and missing some things. Um, I I mean, I I've seen some very, very interesting things. So it's it's always a good reminder that when your patient records are subpoenaed for court, you're gonna have to stand up to whatever it was you documented. So it's not just that, but you know, teaching physicians attesting to the resident documentation. I tell them you're not just attesting to the parts you wrote, you're you're attesting to the validity of the entire thing, including what they wrote. So I mean yeah, just document like like you were like your life depends on it, and like you do not look good in orange or horizontal stripes, and you don't want to go to gym, like document it, um, not just for patient care, but also to ensure that the person taking over after you has a clear understanding of where the patient is at today and the plan moving forward from your perspective, so that there really are hopefully no gaps.

CJ Wolf: 24:02
Yeah, and that's really what you know medical documentation is about. It's it's it's it's about that continue continuum of care for this patient for this episode, whatever it might be, right? Yes. Um, like you were saying about the patient in the hospital and and the doctor had the exact same note for 17 days. That doesn't really tell me. Let's let's say I get consulted, I'm an infectious disease doc or somebody else. It's like I can't really tell what's happened with this patient for 17 days because it looks like the same. So I learned nothing from your 17 days of of medical records.

Amanda Reikowsky: 24:38
Exactly. And I think the last like little the subjective for your patient's day is subjective, patient scene sitting up, no acute events overnight, and then you're billing a level three. Yeah. Like, like you're that you said they were fine. They're sitting up in bed, no, no acute event. Like, what do you what do you mean it's a level three? Like, help me like help me make that make sense. Like I aging myself a bit, but I always said make them as sick on paper as they were in the room. Now we don't have paper charts anymore, but that's right, don't say things out of habit of saying things. They may have had no acute events overnight, but they're probably not sitting up in bed and having a great time, probably. And if they are, it's probably not at level three.

CJ Wolf: 25:24
That's right. Yeah, such a good, such a good way to say it. Well, Amanda, we uh really, really appreciate you uh sharing your thoughts and expertise. Um, so thank you so much for being on the show today.

Amanda Reikowsky: 25:36
Oh, thank you for for having me. I had a really good time, CJ. Thank you.

CJ Wolf: 25:40
Yeah, and uh I think you said you'll be at at HealthCon. So uh hopefully I'll see you there.

Amanda Reikowsky: 25:45
Yeah, absolutely. We'll be doing uh VATS procedures. So yeah, definitely looking forward to that talk.

CJ Wolf: 25:51
Awesome, awesome. I'm looking forward to that too. And thank you to all our listeners um for listening to another episode. Uh, as we always like to say at the end, uh if you have uh topics that you'd like to hear about, let us know what those are. And if you know of somebody that's an expert like Amanda that uh would be a great guest, uh please share their name with us as well. And until next time, everyone, take care.