Having lived in and around Philadelphia for most of my younger days prior to living in Milwaukee, three things still hold true about me: I prefer cheesesteaks and hoagies to bratwurst, I drive extremely fast compared to others in my new adopted home and I’ll forever be a rabid sports fan.

My hero growing up was Steve Carlton of the Phillies, a pitcher so inscrutable and so focused on getting people out that the only nickname teammates could come up with for him was “Lefty”. With each passing day, in a world of pitch counts and fanatical devotion to quantifying every at-bat with statistics, I appreciate Carlton that much more. He was the classic power pitcher, going in for at least 7 innings, throwing a baseball as if his life depended on it, then strolling off the field with his eyes looking down to the unexpected applause of a sports city known for such class acts as booing the Easter Bunny and pelting Santa Claus with snowballs.

Every one of his 4,136 strikeouts was a testament to mental discipline and a workout regimen that included, among other circus-like feats, driving his fist to the bottom of a bucket of sand. This devotion to his workouts yielded 329 wins and a ticket to the Hall of Fame.

So what does Steve Carlton have to do with the Recovery Audit Contractor program? Bluntly, it’s about time you asked.

Most physicians, based on the years of training involved with becoming a member of their profession, possess a certain level of discipline. Fortunately for their patients, and unfortunately for themselves, this discipline often includes only the practice of medicine and does not extend to the documentation of the services rendered to their patients. The RAC’s have already taught us many lessons, but one painful lesson on the horizon is how much of a disservice physicians do to themselves by not capturing all that they do in a clinical setting in the patient’s medical record.

As RAC’s now expand their focus to include medical necessity, with more attention being paid to physician services, there is a school of thinking that the best beginning course of action for physicians to identify their RAC vulnerability is a review of CMS’ Comprehensive Error Rate Testing (CERT) reports and specialty peer comparison of billed services. Unequivocally, I agree that this is indeed the best place to start, but once this first step is completed, the hard work begins. Specifically, it’s time to take a long and critical look at the documentation for your services. This is the point, in today’s and subsequent postings, where I’d like to insert myself into the larger conversation.

Creating “audit-proof” documentation is far from an easy task. For one thing, “medical necessity”, as any person at all connected to medical delivery will tell you, is not a one-size-fits-all proposition. Similar symptomology can have different effects depending on the presentation of the patient. This inconvenient fact places the burden of proof for medical necessity squarely in the hands of the treating physician and his or her documentation of the services rendered. With CERT reports indicating that the biggest risk area for physician audit being evaluation and management services, it is long since past the time to look at documentation of these services.

It has been 15 years since the first E/M guidelines were released by Medicare. With the volume of writings dedicated to documentation of E/M services, you would think that physicians would be at least halfway to resolving documentation inconsistencies, but this simply isn’t the case. It is my belief that the problem lies not in wanton and deliberate physician non-compliance, but rather a lack of an attempt by CMS to translate the E/M guidelines into usable clinical language that physicians can understand and utilize.

With mandatory electronic health records on the horizon, the absolute worst line of thinking a physician could internalize is “the EHR will handle it”. EHR’s possibly offer a solution, but only if set up in the clinical setting to be utilized properly. EHR’s can lead to such things as templated and cloned documentation, which in established patterns can bring exponentially increased risk. Remember that the main reasoning behind the government’s push for EHR is simplicity and portability of retrieval, and not as a panacea to documentation of services.

Because I tend to look at RAC audits of physicians from this angle, I’d like to offer a preview of next week’s edition of The RAConteur, where I’ll begin taking a look at the most common CERT E/M errors and offer analysis you can use to make better decisions about code selection, beginning with subsequent hospital service codes 99231 thru 99233. I can promise the reader ahead of time that finding permanent and lasting answers will require discipline, but much less than is required to plunge your fist to the bottom of a bucket of sand.

10:40 am, September 8th, 2010 |