Do You Have the Perfect Drive? Perfecting Your Tee Off is Similar to Your Documentation Improvement

  • Gretchen Dixon CCS, CHCO, AHIMA Approved ICD-10 CM/PCS Trainer
  • Volume 10 - Issue 1
Our challenge for 2019 is to perfect your golf drive by performing a mental checklist as you stand at your tee addressing the ball.
 
Clinical documentation improvement is very similar to your golf drive mental checklist. Before you begin your documentation, it is important to know the reason for the patient’s encounter (standing in front of your tee) and then to identify and document all relevant information in the medical record.
 
The KEY SOURCE supporting a patient’s need for an encounter is your clinical documentation. Our articles continue to focus on physician clinical documentation specific details. Why? The Centers for Medicare and Medicaid (CMS), the Office of Inspector General (OIG, and other third party payers also recognize these same clinical documentation weakness, which is why you may receive letters from your CMS Medicare Administrative Contractor (MAC) or the OIG requesting overpayment investigation and monies returned. It is in your best interest to be proactive and improve the clinical documentation. Week after week performing provider/physician documentation audits, the discovery continues to find clinical information conflicting, inadequate, incomplete or vague thus not supporting medical necessity for HBO therapy. So how can your documentation support diagnosis(es) and/or procedure codes (CPT codes reporting Evaluation Management encounter, procedures) when the information is not there?
 
Within this article, while sharing the similarities between clinical documentation and your tee off performance, we are focusing on a similar goal of improved performance. This is manifested by helping to straighten out your drive and add value to your clinical documentation.
 
An instructor analyzing your golf swing can break it down motion by motion with an understanding of how much a small change can affect your swing speed, club striking position with the ball, the path of the ball and the speed at which it travels down the fairway toward the green. Our clinical documentation takes on the same methodology if we pay attention to the small details.
 
To begin with, the game of golf has three separate components or mini-games (the drive, the fairway shots, and the short game—putting on the green) which makes it a complex and difficult game for anyone to play whether you are an amateur or a professional. Most of us who play golf are amateurs who enjoy the challenge of every stroke. The first mini-game is the drive off a tee at each hole. This action shot sets up the rest of the strokes toward the hole until that little ball falls into the cup. Without a long drive down the fairway, your par (score) could be in jeopardy, meaning you may not make the par 4 to be on your score card for this hole. Your dream of a birdie may turn out to be a bogey (scoring 1 shot over par for a hole)—Ouch! This translates to a par 5. Yes, this does relate to your clinical documentation!
 
When setting your tee, you mentally go through all of the points in preparation for your perfect drive swing, and then you begin a couple of practice swings before addressing the ball. “Whack!” sounds your driver as it connects with the ball, sends it up in the air, looking great, and then it suddenly fades into a slice (ball veers to the right) off the fairway into the tall rough out of bounds. Oh no—a lost expensive ball and what is worse— lost strokes—as you mentally see your par fading away for this hole and for the game. What went wrong? How did that happen? What are my peers thinking? This could be a long hardgame.
 
Some days you just feel alone—anyone who has played golf knows it can happen to anyone at any time. Clinical documenters are similar to golfers because of the number of mental activities which must be accomplished simultaneously. It is these mental activities which may cause distraction from documenting thoroughly and completely. Your clinical documentation only has to provide the facts
as well as linking findings and information to the reason for the visit. Just listing a problem or medical condition does not adequately demonstrate medical necessity for the visit, especially when HPI (History of Present Illness), ROS (Review of Systems), and PE (Physical Examination) are inconclusive with limited information.
 
As a clinical documenter, you have to be on your game to ensure you are able to gather all of the necessary information to make a medical decision and support medical necessity of services. Many patients have complex health concerns and require close monitoring; however, without clear, concise, accurate, and factual clinical documentation, it is often difficult to determine the provider’s thought processes for treatment. This affects the patient and other healthcare providers who need to follow through with various aspects of his or her medical care.
 
Practice, practice, and more practice with adding specific details in your clinical documentation are necessary to ensure our outcomes are as required. A single habit took 90 days to make it a life routine, so chin up, smile on; we can make our clinical documentation meaningful for the continuity of patient care. Let’s look at the dynamics between the golfer’s swing and a provider’s clinical documentation for a visit in a medical record and discover the similarities. As you review the similarities, each item relates to the previous activity and all of the activities result in a final outcome.
 
  Golfer Provider Documenter

1

Do you have the correct club for the distance you have to drive the ball?

Are you with the right patient and have the correct medical record for this patient?

2

Did you tee your ball to the correct height to favor your driver? (Too high and you will not have the expected ball distance to reach down the fairway)

Do you have the appropriate date of service documents to begin gathering information during discussion with your patient?

3

Is your stance correct with your feet shoulder width apart? (Wide enough for stability but narrow enough to promote a full body turn)

Chief compliant or reason for the visit documented

4

Is your grip tight enough or too tight on the club handle to prevent rotation of the club face? (Grip was not good: left thumb was not tightly held into the palm of the right causing the club face to turn rotate slightly just before impact)

HPI—History of Present Illness
Were questions asked to obtain answers related to the reason for the visit noted in the any of the eight elements?

  • Location—body area or specificanatomy
  • Quality—related to type of pain—dull, sharp, stabbing, radiating or laceration described as jagged, straight, or sore throat as scratchy
  • Severity–measure of pain on scale of 1 to 10
  • Duration—when did the symptomsstart
  • Timing—recurring, comes and goes, etc.
  • Context—how the complaint occurred
  • Modifying Factors—What steps has the patient taken to alleviate the symptoms
  • Associated Signs and Symptoms—Usually volunteered by patient and information does not fit into any other category

5

How is your form? Is your head down, eyes locked on the ball? (Moved your head, took your eyes off the ball)

ROS – Review of systems related to the reason for the visit—Noting no abnormality does not necessarily provide supporting documentation for medical necessity.

6

Beginning your take away (back-swing), keeping your left arm straight. (Weak drive due to collapsing left arm—lost distance and accuracy. No chicken leg elbow effect. Left shoulder can turn under your chin.)

PE — Physical examination related to the reason for the visit and information in the HPI

7

Hit through the ball, head down (no movement) wrist remains cocked on release as the club face strikes the ball. (Drive distance could have been better if your head remained still and with your eyes focused on the ball.)

Assessment—diagnosis(es) supported by evidence documented
during the visit

8

Finish the swing with a full rotation of your hips with your belt buckle facing the green. (Not quite as flexible as you should be–you may need to use the practice range to warm up before a game)

Plan – decision making process linked to evidence documented
during the visit
Discussion with patient including questions and comments from
the patient
Orders documented

9

The ball would have went the distance if it had not faded (turned right) into the pond, the tall rough or woods. What caused the fade? This happens when we take our eye off the ball, move our head and allow the handle of our club twist.

What is in it for you? Game improved—

  • Improving accuracy of drive
  • Pars recorded with fewer bogies
  • Pars equal a better game
  • Golf score above 36 such as 40 is not bad and should bring smile with thoughts of the next game

Documentation errors or inconsistencies happen when we lack
focus on what we are doing. Correcting these inconsistencies will take patience, education, and practice to improve both.

What is in it for you? Process improved—

  • Clinical information supports medical necessity
  • Reduced questions from your coders improve code
  • Improved code selections
  • Reduced third party request for additional information and/or denials
  • Reimbursement more accurate and timely

Regardless of what we wish for, we need to continue to be proactive with clinical documentation within the EHR (Electronic Health Record) or the EMR (Electronic MedicalRecord).

Medical Necessity Has Two Tees

In the last six months of 2018, I have been involved with clients regarding a request from the Office of Inspector General for HBO services and identified overpayment. The clinical documentation review was a disaster to find the medical necessity. Here is the relationship between your golf game and your clinical documentation. The first tee is long (31⁄2 inches), representing clinical documentation by the provider believing the information will support the services provided. The second tee is shorter (2 inches), representing how the payer determines medical necessity. We all know documentation must support the clinical medical necessity of the visit; however, the meaning of the term “medical necessity” may be different between physicians/providers and Medicare or third party payers. The difference is between clinical medical necessity and billing medical necessity. As a provider, you may believe the service is medically necessary; however, the payer may not interpret the services as such. Ouch! Your drive only went 150 yards—not your usual drive of over 200 yards. Therefore, it is advised to review and understand each payer’s expectations noting the commonalities among payer’s expectations.
 
So what should your documentation include in each visit? Just like getting ready to tee off for your next drive, think about the relationship of where you are (beginning a visit) and how many strokes it is going to take you to get to the pin on the third hole for a par 5, 525 yard hole (What is the patient’s story?)

IMPORTANT TAKE AWAYS

  • Tell a story about the patient’s reason for the visit.
  • Document all relevant elements as to the reason for the visit. Don’t assume other health care team members or external reviewers/auditors have the same level of knowledge you have.
  • Link the identified diagnosis to HPI, ROS, PE, and medical decision making process.
  • Know your payer’s medical policies and document in their terms when possible.
A simple example is trigger point injections. These are often performed and considered simple in the clinical setting, however, it is the documentation which is more complex. Therefore, this is a good demonstration regarding the amount of detailed information your payers may be looking for and, if not found, a denial may result. Trigger point injections’ indications/limitations/documentation requirements often differ between Medicare Administrative Contractor’s (MACs) Local Cover Determination policies (LCDs). This is where the emphasis in this article is to focus on patient related details thus providing a complete story of your patient’s encounter. Review your LCD for the specifics as one may be more detailed than another. However, by including the below information, your documentation will be clear, concise, and thorough to support medical necessity.

Clinical Documentation Requirements

Documenting the following items may result in a reduced risk of denial if there is a detailed history and thorough physical examination:
  • History of onset of the painful condition and its presumed cause (injury/sprain)
    • Location
    • Duration
    • Failed therapies
  • Distribution pattern of pain consistent with the reason for the visit
  • Range of motion restriction
  • Muscular deconditioning in the affected area
  • Focal tenderness of a trigger point
  • Palpable taut band of muscle in which the trigger point is located
  • Local taut response to snapping palpitation
  • Reproduction of referred pain pattern upon stimulation of trigger point
  • Conservative therapy has not provided acceptable relief, is contra-indicated or not appropriate
  • Plan/Goal:to treat the cause of the pain and not just symptoms
    • Note the reasonable likelihood the injection will significantly improve the patient’s pain and/or functionalability
  • Diagnosis must not be generalized like low back pain—may be considered non-covered
  • Be as specific as medically possible with your documentation

Limitations: 


  • No more than three injections in a three-month period by one payer
› Another payer notes more than four injections 
per year will not be covered 
  • If the injections are performed more than three 
injections in three months, the reason for the additional injections must be evident in the medical record and available to the contractor for review. 

  • Documentation in the medical record must support the medical necessity and frequency of the trigger point injections. 

A lesson to learn from a trigger point injection documentation is to understand the value of details needed in the clinical documentation assessment of the patient regardless of the provider’s specialty of practice. The pleasant sound of your driver hitting the golf ball in the perfect spot produces a welcome “whack” as you watch your drive fly up and straight down the fairway passing the 200- yard marker on your first hole. Now the pressure is on because you have to remember exactly what you did right to accomplish this wonderful feeling. It is in the details of what we do every day. The game of golf is very precise just the way your documentation needs to read.
 
Pay attention to the little details for big results—a birdie (one stroke less than par for the specific hole)! As we continue to learn to code in ICD-10-CM (diagnosis coding), the little clinical details you begin to add to your clinical documentation will support a more accurate diagnosis code thus meeting medical necessity of provided services. Hope to see you on the golf course with long straight drives—your documentation tells a story filled with details; it is thorough, relevant, and easy to understand.

References

  1. ICD-10-CM Coding Manual, published by Optum360, October 1, 2018 through September 31, 2019.
  2. NCD Risk Assessments October 15, 2018 relating to HBO. Author Dr. Arthur Peterson published by HCCA Webinar.
  3. The New Future of Hyperbaric Medicine, Medicare Regulation with Targeted Probe and Educate, dated March 1, 2018 located in Todays Wound Care magazine
  4. Cahaba Government Bene it Administrator (GBA), LCD ID Number L30066 Surgery: Trigger Point Injections http://www.cahabagba.com/part-b/medical-review/local-coverage-determinations-lcds-and-article.
  5. Checklist for Hyperbaric Oxygen Therapy March 28, 2018 addressing specific clinical documentation of diagnosis in the HPI and Progress Notes to include measurable signs of healing.

About the Author

Gretchen-Dixon
GRETCHEN DIXON, Independent Revenue Cycle Compliance auditor who performs audits regarding the outpatient revenue cycle healthcare compliance arena. She has conducted compliance education and audits for outpatient departments and physician services with a focus on wound care department operations for more than fifteen years. Gretchen is a faculty member of Wound Care Education Partners, teaching on the topic of “Business of Wound Care & Hyperbaric Medicine” and conducting webinars. She holds several credentials including an MBA in healthcare management; RN with a practicing license in New York and a 23 multi-state licensure from Virginia; AHIMA approved ICD-10-CM trainer and CCS; and is a certified healthcare compliance officer. As a longtime internal healthcare auditor, she identifies issues through audits of documentation, coding, and billing practices. The outcome of each audit determines the topics of education to be provided to the staff and physicians as she proactively believes education is the key to having complete, accurate, and consistent documentation for accurate reimbursement of billed services. Contact her at This email address is being protected from spambots. You need JavaScript enabled to view it. or 615-210-7476 for more information.
 

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