Early documentation instruction sorely lacking

Last week, during ICD10monitor’s Talk Ten Tuesdays broadcast, Larry Field, DO, treasurer of the American College of Physician Advisors (ACPE), shared the tale of a relatively new hospitalist who was disenchanted with medicine and considering a transition into physician advising after only three years of practice. Dr. Field expressed what a lot of doctors feel – an assertion that the electronic medical record has significantly impacted their ability to care for patients. When Larry previewed his piece in our pre-show discussion, it triggered some thoughts for me. Here they are:

 One of the reasons providers are so unhappy is that they get next to no instruction on documentation while in training. As they progress in residency, they muddle through documenting of the patient encounter, guided by their superiors, who also have no formal education on documentation. Those superiors were also trained in paper charts, so they are trying to replicate what they used to do with the technology they have available now. Any minimal formal documentation education providers receive in residency is from the medicolegal perspective, i.e., how to cover your you-know-what.

I am the course director of the Intensive Course in Medical Documentation: Clinical, Legal, and Economic Implications for Healthcare Providers, through Case Western Reserve University School of Medicine, which is presented three times a year (http://case.edu/medicine/cme/courses-activities/intensive-course-series/medical-documentation/). Our principal audience is providers that have run afoul of their state medical boards and have been mandated to take a course in medical documentation, but recently, more attendees have self-selected just to improve their expertise in documentation.

When compelled to take the course, attendees are often disgruntled and sometimes even hostile at the onset. By the end of the second day, they nearly unanimously thank me and the faculty for an excellent course, often lamenting, “Why didn’t we learn this in medical school and residency?” I have no answer for this question, but I believe it is partly why providers feel overburdened by documentation requirements they believe are foisted on them by the government.

My opinion is that the government wants us to take good, efficient, cost-effective care of our patients (their enrollees). Until Big Brother can physically or virtually be present in the room with the patient and provider, the only mechanism to know what service/s were provided is to review the documentation, which presumably has recorded what transpired.

Do you think knowing what medications a patient is taking, or whether they smoke, drink, or do drugs is clinically significant? I do. Is the review of systems just busywork? If a patient who presents for an ankle sprain admits to dizziness and black stools, the encounter uncovered pretty important, actionable information. Does being explicit in your medical decision-making (MDM) help substantiate medical necessity, communicate to other providers what your thought process was, and improve patient care? I think so. So the documentation requirements for evaluation and management (E&M) levels of service may not be so capricious after all.

Documentation isn’t an added burden; it is part of the service. If you get a house inspection, is your expectation that the inspector is merely going to assess your home, or give you a detailed report on which you can act? Clinical documentation is a necessary element of the patient encounter.

Providers have the mistaken impression that the more you document, the more you can bill for a level of service. They should be referred to the E&M guidelines: (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf), which clearly detail the general principles of E&M documentation and how it relates to codes. Specifically, they say “you should not use the volume of documentation to determine which specific level of service to bill.” When I am educating providers, I try to emphasize that the key is quality, not quantity, of documentation. 

The last misconception that needs to be dispelled is that teaching advanced practice practitioners (APPs) or residents is sufficient. The provider is held accountable for any documentation done on their behalf. It is not only E&M professional billing that hinges on the documentation. Quality metrics and the technical billing are also derived from documentation. The quality metrics are assigned to the physician, not the APP or the resident. It is, therefore, in the clinician’s best interests to ensure that documentation is of the highest quality.


If you don’t know what is required of you, it is hard to produce high-quality documentation. Here are my recommendations:

  • Read the E&M guidelines for yourself. If they are at odds with what your mentors told you during training, dismiss your prior instruction. It is not about volume; it is about clear and concise medical record documentation reporting the care that a patient received, validating the medical necessity and appropriateness of the services provided.
  • Make the documentation work for you and the patient. Everything you document should be valuable in detailing what is or is not happening with the patient. Copying and pasting previous documentation is only useful if it advances the care of the patient. If you are doing it to bloat the volume of the record, don’t do it! Did I mention it isn’t about the volume? Also, if you are using copying and pasting correctly, it often takes more time to review and edit it so it is accurate today and now than it does to generate the documentation de novo. You are really paid for your cognitive effort and your clinical acumen – your documentation should demonstrate that.
  • Medical decision-making is key. There is a current push to revise the E&M requirements and make MDM king. I support this, but I am not in favor of completely eliminating history and physical requisites.
  • If you have access to electronic medical record (EMR) experts in your organization or office, recruit them to help you leverage the EMR to assist you, not impede you. Make good templates. Create accurate, useful macros/smart phrases. Would voice recognition work for you?
  • Consider using a scribe. The dissatisfaction the provider shared with Dr. Field was due to the degradation of the face-to-face patient encounter. We don’t go into medicine to take care of a computer keyboard. Study after study demonstrates that using a scribe increases provider productivity and improves patient and provider satisfaction (I do not own a scribe service, but wish I did!)

It is unfortunate to lose excellent providers because they can’t tolerate documentation requirements, but it is particularly silly for new providers to not know what is expected of them in the first place. When I was a physician advisor, I established a whole curriculum for residents to holistically learn clinical, medicolegal, and billing documentation. If you work in an organization that has a resident program, demand formal documentation education. Today’s residents are tomorrow’s healthcare providers. We want well-trained, professionally content, competent providers taking care of our patients and us. They can become physician advisors eventually, after a satisfying clinical career.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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