Hey Everyone. We’re counting down to our Advanced Coding Strategies Conference in October and I am very excited about the things we will be discussing. At the conference, I’m going to take about 30 minutes and go over what I call Documentation Shortcuts. While there really aren’t any ‘shortcuts’, there are several things that can be done by you and your staff to make your life MUCH easier. Here’s one of my favorites:
Many of us are in the habit of the nurse asking the patient “what are you here for today?” and then putting a small note on the chart. Basically the Chief Complaint. One thing I’ve done in my clinic is I have my nurses write out the History of Present Illness instead. When we first started this it was a disaster. I would have things on the chart like “Patient is here for sick” or “Patient is here for follow-up of med follow-up.” Stuff like that. Here is what I taught our staff to do. Ask the following four questions:
Notice what we just accomplished. My nurse has documented 4 elements of HPI (location, duration, alleviating factors, and associated signs and symptoms). If any of these are negative, they make sure and write it as negative. This turns in to the following 3 sentence HPI:
“Patient here for 3 day history of sore throat. Motrin helps. Also having fever and URI symptoms.”
“Here for 2 weeks of allergy symptoms. Hasn’t tried any medicine. No fever.”
“Here for coughing since last night. Cough medicine didn’t help. Subjective fever.”
Before I ever go in the room, I already have a complete HPI. Sometimes I have to change or add to it. But as my nurses have improved, often I don’t have to change a thing. I skip ahead to document the physical exam and decision-making.
Don’t forget I’ll be hosting Advanced Coding Strategies in Dallas on October 15th. Over the last several years we have worked to provide the best coding instruction available for physicians. We appreciate the help and support you have given us. Our annual Coding Growth Strategies seminar focuses on how we can quickly and accurately identify the type of patient that we’ve seen then document accordingly.
After every conference and newsletter we release, we have many questions that come our way. Some of these are simple coding chores but often they are a little more challenging to figure out. Over time I have come to call these ‘advanced coding’ topics. These bring up several issues that aren’t covered in our normal day-to-day coding. We have compiled these into a 4 hour session that we know will be helpful to your practice.
The conference will start out with a few minutes of review and ‘touching base’ for those that have attended before (Remember the color-coded Risk sheet?). Please Note: this is not an introductory course! It is expected that the attendees will have already completed our regular 6 hour Coding Growth Strategies course and we will not go back over what we have already learned. You should be comfortable with identifying the patient’s level of risk, medical decision making, and have a certain level of proficiency with coding 99213, 99214, and 99215 codes.
This is the ‘part 2’ of the course. We will immediately dig in to some of our more challenging topics in the day-to-day practice.
After becoming familiar with multiple challenging examples, we will then discuss Documentation Short Cuts. While there are no ‘short cuts’, we will talk about several items that can streamline your documentation so that you spend less time writing, and more time seeing patients.
One thing I’m very excited about is our ‘lightning round’. Here, we will have the attendees submit some of their coding challenges ahead of time and we will discuss them as a group. We will identify the patient and first ask ‘what should be the level of service?’ quickly followed by ‘is this note adequate?’. That way instead of using pre-made examples, we will use actual patients seen by you.
This will be an exciting course, hope to see you in October. DVD’s will be available by the end of October.
Sign up for the Advanced Coding Strategies live presentation
Pre-order the Advanced Coding Strategies DVD/CD at (available October 25)