The Missing Ink Podcast - Episode 1
Erin Galloway (00:00):
Welcome to The Missing Ink. The documentation education team strives to bring education in various platforms and is thrilled to be able to add podcasting to that list. Today we are excited to have our first inaugural podcast. I am Erin Galloway on for the Senior Directors and documentation and will be the facilitator for today's podcast. And with me is Dr. Zach Goldman to discuss all things 2023 guideline change related. Dr. Goldman is an envisioned emergency medicine physician in Dallas and is a National medical Director and vice President of Clinical Documentation. Welcome Dr. Goldman.
Dr. Zack Goldman (00:32):
Thank you so much Aaron. Thanks for allowing me to participate in the inaugural podcast. This is very exciting. It's great to bring information to our envisioned clinicians and colleagues being these different formats.
Erin Galloway (00:45):
Okay, Dr. Beman, everywhere I turn these days, I'm seeing and hearing about changes in the 2023 evaluation and management guidelines and then apparently it's a big deal. So what's changing and who does this impact?
Dr. Zack Goldman (00:58):
Okay. Starting January 1st, 2023, the e and m codes, which is the evaluation and management codes, or typically the hospital codes we use will be determined by medical decision making or MDM only to make it a little bit more complicated. Even though medical decision making has always been a factor in assigning an e and m, how medical decision making is determined is also changing. We get the double whammy. This will impact the majority of our envisioned clinicians to some degree. The largest impacts are in those in the hospitalist service such as hm, OB peds, our ED clinicians, and our surgeons.
Erin Galloway (01:43):
Interesting. So now that coding is based solely on medical decision making, that means you don't have to document a history and physical exam anymore. Right.
Dr. Zack Goldman (01:53):
I knew that was gonna be the question you were gonna ask. Well actually you still need to document a medically appropriate history and physical exam. This is left to the discretion of the clinician seeing the patient. That said, it's really important to understand that clinical documentation is impactful on several other areas outside simply assigning an ENM level of service. The history and physical examine assists in accurately capturing the quality severity and intensity that patient in front of them. The documentation paints a picture of the clinical encounter and captures a patient's condition and is the basis for the clinician's thought process. These elements also substantiate the medical decision making help capture quality and mitigate risk. So long answer is you still need to document an appropriate history and physical exam.
Erin Galloway (02:47):
Okay, gotcha. Now that's a lot of information on mdm so can you kind of break that down and tell, tell us what makes up medical decision making?
Dr. Zack Goldman (02:56):
Sure, and this is probably the most boring part of this conversation, but medical decision making is broken down into three separate components and this has always been the case. Their titles may have changed a little bit, but more importantly what makes them up has changed and that would be a lot more of maybe what we discussed later today. The three components are number and complexity of problems addressed during that specific encounter. Two, a amount complexity of data to be reviewed and analyzed. And three, the risk of morbidity, mortality, lots of words but three different sections. And to assign a level of medical decision making, two of the three have to marry up to assign that final e and m level.
Erin Galloway (03:43):
So do you have any pointers on how our clinicians can clearly paint that picture of the complexity and severity of the patient that's right in front of them on that specific date of service?
Dr. Zack Goldman (03:53):
Yeah, and I love what you just said on in front of them on that specific date of service. So we're talking about every unique encounter and one of the things we want to do is focus on the key words that the patient gives us regarding their condition. Is it acute? Is it chronic? Is it mild, moderate, severe? Is it an exacerbation, is it a severe exacerbation? These words help paint the picture, tell the story of what's going on. There are other things too. We can use the diagnosis itself. There is a difference between a patient who has say anemia and severe anemia or they have moderate acidosis. Additionally documenting the differential or the rule out diagnoses of what conditions you may be worried about or considered. And those that you have actually ruled out. Paint a picture of just how sick the patient in front of you is, or more importantly could be.
(04:53):
Don't forget to include any chronic conditions that may impact the patient's condition and your decision making. Many patients have a specific clinical complaint, but they also oftentimes have other medical conditions such as hypertension, diabetes, or electrolyte abnormalities, excuse me, impacting their presentation. It must be clear that these conditions were addressed that day and not just listed in the past medical or family history. Finally, like what we talk about with IC 10 when it first came out, we want to document the most specific and appropriate diagnosis we can. One of the most common examples I always like to think about is shock, especially sepsis and sepsis related to shock. There is a specific difference between a patient who presents with say sepsis or severe sepsis or septic shock or has pneumonia but actually has respiratory failure and hypoxic respiratory failure secondary to pneumonia. We are clearly going to treat the patient in front of us based on their conditions, but these specifics help capture that condition more accurately.
Erin Galloway (06:04):
I'd like to back up to one of the first things that you mentioned here and you stated this unique encounter. Can you tell me a little bit more about what you mean by that?
Dr. Zack Goldman (06:14):
Yeah, I think this is a really unique and a specific call out that what we need to do is be able to paint the picture of what happens on that specific day and all the documentation that we're talking about should capture and support the complexity of care delivered and provided on that day. For example, what problems were addressed, what medications were ordered, what diagno diagnostics were done on that particular day. When patients are in the hospital for more than one day, sometimes when I review charts it can be really difficult to determine on what exactly happened on that date of service. I can't stress this enough, especially on subsequent visits. The documentation for that date of service should stand alone, paint a picture of what was done that day, what was the clinical concern that day. I think you hear me reiterating and reiterating that term that day. But I think that is what we are trying to capture. Can we paint a picture of the care we delivered to that patient and once again on that specific day?
Erin Galloway (07:30):
Got it. So I think what you're saying is on that day, right,
Dr. Zack Goldman (07:33):
Yes, that day.
Erin Galloway (07:35):
Got it. Okay. So next question. When documenting data, we know most of these EHRs automatically bring in your labs and other diagnostic imaging orders. What are other items that our clinicians should be aware of that are considered part of data?
Dr. Zack Goldman (07:52):
Yeah, I think that's a great question and obviously as you said, it makes up one of the three components of medical decision making. So I think I wanna start with the first part. Sometimes I think we assume that the EHR brings in that information and I think we wanna make sure that that information actually is captured in our medical record and not somewhere else. If it is captured in the medical record, the tests you order, the blood work order or the diagnostics you order, then yes, that'd be great. Populate your chart if it doesn't, it's really important that again, on those unique encounters, that information is part of your note and you're capturing it explicitly. Other areas to consider related to, you know, that second element of medical decision making and the data section is did you need to in get information from an independent historian? That's pretty straightforward. If the clinician needed history from another historian, you need to document who the historian is and why you needed the information. For example, the patient's nonverbal, so history was obtained from a parent or the patient has severe dementia, so you had to get the information from a family member. Again, the key is capturing the who and the why.
Erin Galloway (09:09):
So quick question on that. Many times we know clinicians have to use an interpreter to assist with taking care of a patient. So does an interpreter count as an independent historian?
Dr. Zack Goldman (09:20):
Yeah, great question. And the simple answer is no interpreters don't count as an independent historian as they relay the information that the patient has given you, they're not actually providing the history themselves.
Erin Galloway (09:32):
Okay. So the next question is, I know the guidelines also discuss reviewing external notes. Do the clinicians need to specifically state external notes reviewed?
Dr. Zack Goldman (09:45):
Yeah, I think that's a great question. And it's a little bit of a matter of semantics. Let's first describe what an external note is. By definition an external note would be a note outside of your local specific group and specialty. So I think okay, that makes sense. But in reality I think the best practice is yes to comment on external note if you can, but in reality document the work that you've done. So if you review an old note, document what type of notes you reviewed and what your findings were related to that note, I think one, it captures medical decision making and two, it's really important for good medical care cuz this information often impacts how we may treat the patient or what we may be concerned about. And think about all the different types of notes this may be, this could be ED notes, it could be case management note, it could be a primary care doctor note, it could be a consultant note if you have to review a prescription drug database. So again, there's lots of possible notes that we review often during the care of the patient. Take home point is if you review a note, document the note type and what you found through your review.
Erin Galloway (11:02):
Great. Are there any other data points that we need to cover?
Dr. Zack Goldman (11:07):
Yeah, I think there is and this one we want to call out again uniquely and specifically if you independently interpret any diagnostic test like an EKG or an x-ray or an ultrasound such as a fast exam or a rhythm strip or an nst, be sure the documenta documentation states that you personally reviewed and interpreted that test along with your impression. Right. This may be something as simple also as comparing one x-ray to another x-ray. Please be aware though that if you're billing separately for these tests such as an ekd ekg, you cannot count that towards medical decision making. Also you can only get credit for one. But regardless the thought process and the workup should be the same If you did the work, make sure your documentation is capturing that medical work that you did.
Erin Galloway (11:59):
Okay, so let me ask you this. So if you as the ED clinician are independently reviewing and interpreting an x-ray but the radiologist also has a separate formal interpretation, do you still get credit for independent interpretation?
Dr. Zack Goldman (12:16):
another great question and the answer is yes. If you take the time to review and interpret the images, this counts regardless of what the radiologist or cardiologist if you're talking about an EKG does. Again, for the purpose of this conversation, we are thinking about medical decision making. So get credit for the work that you do. If you independently interpret an image or a diagnostic test specifically address that with the appropriate documentation of your findings. A last point though on data, before I forget, I'd like to point this out related to discussions or conversations with other clinicians or qualified healthcare professionals. This is really important and this is something we do quite often, but unfortunately our documentation to date does not capture it very well. So if you have a conversation discussion with any clinician or other qualified healthcare professional, make sure you use that specific language such as talked with, discussed with, reviewed with and then who that person was and what you discussed.
(13:29):
It was management, it was a test result. And again, similar to when we talked about reviewing external notes, who are these people we talk to? Well the admitting clinician, the ED clinician, the consultant, the radiologist, case management, P T O T, primary care. How many times on multidisciplinary rounds do you talk to other people? Maybe we're gonna send the patient home and we're gonna talk to their primary care doctor about sending 'em home or back to the nursing home. Again, take home point if you have a discussion with somebody, capture it, use the appropriate language, discuss with or talked with. And then was it involving the management of the patient, the treatment of the patient. But this one is really, really important work we do quite often, but maybe we don't capture as well as we possibly could.
Erin Galloway (14:20):
Okay, great. So let's talk about the third and final component of medical decision making and this is the risk of complications of morbidity or mortality. So can you walk me through like the documentation requirements or when you're considering admitting a patient?
Dr. Zack Goldman (14:36):
Yeah, I think these ones are actually pretty straightforward. I mean if you're, you know, coming from the emergency room, you gonna make the decision, the patient's gonna be admitted. If you're the admitting clinician, you're gonna, you should be documented, the patient's gonna be admitted for observation or inpatient status because of these reasons. So I think that one is pretty clear. There are a couple others though that are a little bit more nuanced. One, what about if the patient has to be transferred to a higher level of care? So they're in the emergency room and you don't have neurosurgery so they get transferred to another facility or they have a super ular fracture and have to get transferred to a pediatric ortho or you're an inpatient physician and you're treating the patient and their respiratory status deteriorates and you have to now change their level of care from the floor to pcu. These are all examples of capturing hospitalization and then the escalation of care.
Erin Galloway (15:33):
Got it. So what happens then if you as a clinician you want to admit a patient but the patient decides to leave ama.
Dr. Zack Goldman (15:41):
If the patient refuses hospitalization leaves AMA or even decides to pursue say an alternative treatment such as home health or hospice. This needs to be documented. The documentation of any of these scenarios clearly depicts your clinical thought process and speaks to the risk to the patient and concern for need for hospitalization. Another situation is when the C clinician is considering hospitalization, that should be documented specifically this would only apply to a small subset of our patients that we see and think after initial evaluation and treatment that they may need hospitalization. But after further workup and treatment that disposition might change. For example, a patient with asthma comes in with shortness of breath, wheezing, re retractions, and you start them on an hourlong. NB treatment gives steroids and monitor them closely for deterioration. After the initial treatment, the patient is better but still symptomatic. The clinician might be considering hospitalization for that patient. If that is the case, the documentation should capture the thought process, what is going to be done to continue to evaluate and treat the patient. And then finally the disposition and why that choice was made.
Erin Galloway (16:57):
So once your patient has been admitted, so they've decided to say you're admitting the patient, what elements really help paint the picture of the risk of that patient?
Dr. Zack Goldman (17:08):
Well I think one of them is related to the medications we give. And there's a couple specific call outs and the guidelines related to parental controlled substances related to high risk medications that need monitoring. Now at times I think we all understand pretty well parental controlled substances, what those are, what are high risk medications? I don't know if we have to memorize those specifically. Theoretically we're thinking about basal active medicines or medications that when we give, we have to think about monitoring the patient closely. We're doing lab values to monitor it. The key again, and we're gonna kind of reiterate this point over and over is we need to capture it though explicitly the fact that we will give medications via a certain route. Oral versus IV in and of itself carries risk, right? Giving an oral beta blocker versus an IV beta blocker has a different risk profile.
(18:03):
The second thing we need to capture is to make sure that we capture if the medication was actually administered because the risk is associated with the medication. Oftentimes we may see notes that say, oh, PRN medication or pain control, well great, but what does that mean? So again, we come back to that same conclusion about can we more explicitly estate this patient needed this medication via this route? And specifically again related to high risk parental control substances and high risk vasoactive medications that we do not, that we actually give fairly frequently through our treatment of our patients.
Erin Galloway (18:44):
So on that same note, one question that we've received a lot during our live trainings is how can the clinician differentiate between high risk medications from general medications in their documentation?
Dr. Zack Goldman (18:57):
Yeah and I think I try to touch on that and probably did a poor job. Let me rethink about that. So I, I think the idea is high risk medications are associated with probably two different pieces. One, their route of administration. I think we just kind of covered that a little bit, that there is a difference between an oral medication and an IV or IM medication. And then the second part is these medications typically require some monitoring either of their respiratory status or of their blood pressure, of their mental status because they have a higher risk of an interaction that may be detrimental to our patient. So again, it's hard to say give a list. I think we have medications. We know, again, we know the list of parental ones. High risk medications, you know are IV blood pressure medications. But some of our other ones also are Geodon are how dolls are insulins. I mean we can make a decision to give insulin, you know, in various different routes, but they’d carry different risk profiles. So I think they'll take home message one more time, capture the route and capture that type of medication that you may be concerned about.
Erin Galloway (20:07):
Got it. So one more question on the risk section. So if your patient has a procedure or you're planning for surgery, does that impact your risk?
Dr. Zack Goldman (20:19):
Yeah, I think we could all agree that having a procedure done especially in the hospital based setting is different than having it done electively. And I think the take home point is two, one, if you as the clinician are performing a procedure, it should be explicitly captured, right? I did an in D or I did a central line or I did a laceration repair. And you use the procedure notes that we typically use. The other piece we need to capture if there's a plan for a procedure or surgery. And it's important to understand that procedures and surgery kind of fall under the same bucket. So if the patient's gonna be admitted and has to have a lap coley or a lap appe and that's the plan that should be actually captured as part of your plan. If it is that they have to go to the endo suite or they have to go to IR or cath lab or they need something like hemodialysis, the fact that they need to come into the hospital to get those things done, increase the patient's risk profile. So can we capture those related to the plan for surgeries or procedures we do ourselves.
Erin Galloway (21:24):
Great. Okay, so another question. So I understand that there's a new factor this year, social determinants of health. Can you explain a little about exactly what that means?
Dr. Zack Goldman (21:37):
Yeah, I think we've all heard about social determinants of health and understand them in kind of our own different ways. They're actually new codes that we're are being tracked related to social determinants of health. But really what we're talking about here is does you know your diagnosis or treatment of the patient? Are they limited by social determinants of health? Some examples could be, you know, homelessness or limited shelter, no access to medical care, alcohol, polysubstance abuse. And the real, you know, goal for us is to make a linkage that this social determinant of health is impacting the patient's condition or their care. Other than that, I don't know if we have to spend too much time focusing on it, just capturing it appropriately.
Erin Galloway (22:23):
One last question on the guideline changes before we wrap up. Are there any changes to the observation codes?
Dr. Zack Goldman (22:30):
Ah, I thought I was gonna get away with not having to address that. Okay. yeah, this is a little bit more nuanced and you know, again, maybe we could have a different discussion, a different day specifically related to some of those nuances. But in, in the big picture of things, for all reality, the observation code sets related to instances of admission and discharge on different days are going away. Now I wanna highlight the, the fact that observation isn't going away cuz that's a service and related to a status of outpatient, but the code set is going away and it's being replaced by the inpatient code set. So your initial encounter for OS is now the same as an inpatient encounter for os. Subsequent encounter for OS is a subsequent inpatient encounter. Now there is one piece I do wanna highlight though. Typically when you discharged a patient from os there was a unique code and that code also is going away and it's being replaced by the typical inpatient codes. And for those who are familiar with it, that's the 9 9 2 3 8 to 9 9 2 3 9 code set. And the difference between those code sets are time spent in discharge of the patient has to be explicitly documented greater than 30 minutes or less than 30 minutes, and not range, but the actual time itself. So unlike the observation code, which at discharge didn't need a specific time, the observation codes for the inpatient code set does need a specific time.
Erin Galloway (24:07):
Perfect. Perfect, perfect. So let's switch gears as we really do wrap up this time. I'm gonna let you take a break from answering questions and let you ask me some. So do you as a clinician have any questions for the documentation education team regarding the 2023 guideline changes?
Dr. Zack Goldman (24:24):
Yes. Okay. My question is this, I know education is going on, but will envision or the documentation, education team supply tips, smart phrases, something that clinicians can utilize at their local facilities?
Erin Galloway (24:40):
Great question. So yes, there are compliance approved emr, macro attest attestation forms that clinicians can use to update their local EHR or other dictation systems. Here's the point though, just remember if you use any macro, it must be used accurately and appropriately depicting the clinical picture and medical necessity of the patient encounter. Also there's a great deal of educational materials that are on the loop and that's everything from a PDF of the presentation to tip sheets to trifolds to the frequently asked questions and even these EMR specific examples.
Dr. Zack Goldman (25:18):
Okay. All right. One last question then I'm notorious for asking one more last question.
Erin Galloway (25:23):
Yes, you are.
Dr. Zack Goldman (25:25):
I've received emails from clinical documentation educators about training sessions taking place throughout the remainder of 2022. How many of these should I attend? What should I do in terms of getting the education that I need?
Erin Galloway (25:40):
Yeah, great question and we get that question quite a bit. So the DACA team really wants to be very mindful of our clinicians busy schedules, and that's why we're offering multiple educational opportunities using a variety of modalities to really accommodate our clinician schedules. So there's web-based sessions as well as help stream modules that are available for any clinician at any time. The request is that the clinicians attend at least one session regardless of modality before the end of the year. So before December 31st, we'd love to have you on a lab training or attending a HealthStream training. I will say though, that we really, really, really encourage our clinicians to attend a live web-based training if at all possible because these are interactive and we have time built in for q and a.
Dr. Zack Goldman (26:23):
All right, that makes sense. Excellent. Thanks for that.
Erin Galloway (26:26):
Absolutely. Dr. Goldman, thank you so much for taking time out of your busy schedule to be in the hot seat today and answering all things 2023 guideline updates. And for everyone listening, please don't forget to visit us on the loop for all your 2023 resource materials and make sure you stay tuned for the upcoming podcast from the missing Ink
