Dear AAPC Region West,

July was an interesting for healthcare policy. First, the government halted risk adjustment payments only to resume them later in the month. Second, CMS proposed a litany of changes to the fee schedule including making History and Examination documentation optional and paying one fee for outpatient Level 2-5 services.

What are your thoughts of making History and Examination documentation optional? During a CMS “Patients Over Paperwork” panel discussion, Dr. Marge Watchorn posed a question by Dr. Michael Warner to Dr. Don Rucker, CMS National Coordinator for Health IT, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible that eliminating, or making optional, History and Examination documentation requirements will undermine patient care and big data efforts?”

Dr. Rucker responded that eliminating History and Exam documentation requirements will actually improve efforts to identify best practices and create predictive algorithms. He used the words “antimatter” and “clutter” to describe information in health records due to the use of templates.

Here is how we feel about the proposal to make the History and Examination optional:

Mike:

I agree with Dr. Rucker that health records are a mess. Mary and I will address template use, copy & paste, cloning and copy forward functions at the AAPC Regional Conference, Anaheim in September 18th. While reducing template information will remove useless information, I have reservations about eliminating or making the History and Examination optional. I fear that documenting only Medical Decision Making (MDM) is a dis-service to patient care.

Looking only at MDM is like a math teacher only looking at the answer and not how the student worked through the problem. Let’s say a female has the misfortune to develop ovarian cancer. Initial symptoms can include abdominal bloating and feeling full quickly when eating. Later symptoms can include pelvic or abdominal pain and weight loss. Such non-specific findings make sense when taken together and recognized as persistent and evolving symptoms. Imagine a series of health record encounters that only mention medical decision making? The provider might deduce abdominal bloating as gastro-esophageal reflux disease without reflux [K21.9] and prescribe an H-2 inhibitor like ranitidine (Zantac, Pepcid). If at a future visit, the patient expresses abdominal discomfort and intermittent constipation, the provider may recommend a high fiber diet and diagnose constipation [K59.00]. The key to diagnosing ovarian cancer is recognition of persistent and evolving symptoms. Without the patient’s story (History), it will be more difficult for any medical professional to make an accurate diagnosis and effective treatment plan.

Mary:
I have been following the Medicare Learning Network calls for the proposal to change how physicians document in their patient’s medical records. Many physicians feel they are spending more time typing than touching. To that end as Michael says health records are a mess chart bloat is a real problem as is cloning and copy forward. I agree that an overhaul of template documentation will help. I do agree with Michael that using time or MDM is a dis-service to the patient and to their care. I hope you will join us as we address these issues on September 18th at the Regional Conference in Anaheim.

Sincerely,

AAPC NAB Region West Representatives:

Mary Wood, CPC, CPC-I
Mary.Wood@aapcnab.com

Michael Warner, DO, CPC, CPCO, CPMA
Michael.Warner@aapcnab.com
www.linkedin.com/in/drmichaelwarner