How to Get Better Documentation for Improved Health Risk Appraisals

Discover two coders’ keys for getting better information from doctors.

What advice would you give the medical coder who asks, “My doctor only wants to list the primary diagnosis. How can I convince her to document the significant comorbidities?”

It’s a common problem. When physicians perform health risk assessments of Medicare beneficiaries, comorbidities and other relevant information don’t always get documented.

In fact, providers fail to report over 40% of active chronic conditions, the AAPC reports. And CMS doesn’t validate over 30% of the HCC (Hierarchical Condition Categories) codes used in risk adjustment “due to lack of supporting documentation.”

At MDCodePro, we hear a lot about coders’ frustrations with physicians. But frustration can run the other way, too.

“Coders and doctors are operating with two separate languages: clinical language and administrative language,” Dr. Robert Donnell writes for the KevinMD blog. “Clinical language tells the patient’s story and acknowledges all the uncertainty in the clinician’s reasoning process. You lose a large piece of that when you try to reduce that story to a list of codes.”

We’re convinced the physician-coder gap can be bridged. You can get your doctor to document comorbidities, and a lot of other information they might not currently be documenting. But to get what you need, you must first look at the situation from the physician’s point of view.

Then you’ll be more likely to help them see how the information you need is the information they—and even more significantly, their patients—need, too.

Why Comorbidities Matter in Health Risk Appraisals


Comorbidity documentation makes an excellent case in point.

One in four adults in the U.S. suffers from comorbidities (two or more chronic diseases or conditions at the same time)—for Americans age 65 and older, that figure jumps to three in four—and these comorbidities make care more complex and costlier.

Research from CMS shows “Medicare expenditures on patients grow non-linearly with the number of comorbid conditions,” driving expenses higher at a dramatic rate. The 2017 edition of Multiple Chronic Conditions in the United States reports Medicare spends $8,867 annually on patients with three or four chronic conditions, compared with $5,272 on those with one or two, and $17,640 on those with five or more.

Medicare risk adjustment takes the differences between patient populations into account when evaluating providers’ performances. CMS requires qualified providers conduct annual Medicare health risk assessments of patients to establish “a ‘base year’ health profile for those individuals,” explains the AAPC, and “to predict costs in the following year” for treating them.

As U.S. health care reimbursement shifts toward a value-based model, “risk adjustment can greatly affect physician income,” writes Duke University Hospital’s Dr. John Yeatts, “so it is important to get it right.”

Looking at Documentation as a Time-Strapped Doctor

Do physicians know about comorbidities? Of course.

Do they want to assess patients’ health and well-being accurately? Yes.

Do they know what they document affects the amount they get paid? Guaranteed.

But “getting to the point” and listing only the primary diagnosis may seem like a good choice because their time is so limited, and many feel they already spend too much of it on paperwork.

Doctors spend two hours on EHR maintenance and other desk work for every hour spent with patients, according to a study in the Annals of Internal Medicine. And only slightly better than half of time with patients (52.9%), as during the Medicare annual wellness visit, is “direct clinical face time;” 37% goes to the EHR. What’s more, physicians spend another one to two hours each night doing paperwork on their own time.

So coders shouldn’t be surprised if doctors feel rushed and resistant to requests for even more documentation.

“Medicine traditionally puts the patient first,” Dr. Danielle Ofri wrote for the New York Times. “Now, however, it feels like documentation comes first. What actually transpires with the patient seems like a quaint trifle, something to squeeze in among the primary tasks of getting everything typed into the E.M.R.”

Empathy and Education: Two Keys to Better Documentation

Granted, seeing the situation from a doctor’s perspective doesn’t change the need for robust documentation. But taking the time to empathize can go a long way toward getting your requests for more information heard and answered.

You also need to translate your queries into concrete benefits for both patient and practice. “When querying a physician regarding the medical record,” clinical documentation consultant Gina Stewart, RN told For the Record, “you will never obtain positive results in the long run if you do not educate them on the eventual outcome and purpose” behind your query.

A coder concerned with getting a doctor to list comorbidities can point out how healthy the practice’s patient population appears in records “impacts [the practice’s] profile on outlets such as Healthgrades, Consumer Reports, [CMS], and insurance providers,” as Dr. Drew Siegel told For the Record. If documentation doesn’t reflect patients’ true acuity, not only will patient care suffer; so will the practice’s risk adjustment and reimbursement.

A list of comorbidities belongs in an accurate assessment of patients’ health and well-being, and supports the argument about higher patient acuity. When patients’ conditions are more complex, physicians must use more complex medical decision-making in diagnosis and treatment. The result? Patients are more likely to get the treatment they need, and providers are more likely to be appropriately paid for it.

“Physicians need help understanding that their responsibility for quality outcomes lies in the pen used to provide medical record documentation,” Krauss and Epstein wrote. “Once they understand this, they’ll write what’s true”—including significant comorbidities.

Build Better Documentation into Everyday Routine with MDCodePro

To thoroughly transform documentation in your practice, you’ll have to do more than empathize with busy doctors’ frustration and explain the concrete benefits better records bring to patients and practice. You’ll also want to equip everyone with a simple but powerful way to make stronger documentation and optimal coding a part of the everyday routine.

MDCodePro is the perfect tool for achieving this goal.

It’s really two solutions in one convenient app, suitable for use in both desktop and mobile browsers: a brief series of video lectures presenting a streamlined, simple-to-remember way of documenting patient encounters in a way that makes the most of CMS guidelines, and an easy-to-use code generator that presents the optimal CPT® code for any encounter, from the Medicare health risk assessment to a post-op follow-up, based on the information you input.

With MDCodePro, higher quality documentation becomes an easy and integral part of the daily workflow for physicians, coders, and administrators—not an extra burden anyone has to feel frustrated about.

Sign up for your subscription today and start seeing the difference MDCodePro can make to your practice and for your patients.

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