Doc to Doc Series: Improve Reimbursement by Standardizing Physician Documentation

Let’s put the needle on top of the haystack.

By Mark Laperouse, MD
Strategic Advisor to Ventra Health in Emergency Medicine.

If EMR documentation feels daunting to physicians, imagine for a moment what it might look like from the billing and coding perspective. My vantage point as both a medical director of an emergency services practice and a strategic advisor to a revenue cycle management (RCM) company has given me rare insight into what happens after we providers submit our notes.

A coder’s job is to comb through physician documentation, identify billable services, and assign the appropriate codes. Now consider that RCM companies have claims coming in from dozens or even hundreds of physicians, and each physician has a unique approach to documentation. We put critical notes in different fields, we use similar words to refer to different diagnoses, and we bury the most pertinent billing information under paragraphs of medical/legal description.

In other words, identifying billable services can feel to a coder like looking for a needle in a haystack. It’s time for physicians to put the needle on top of the haystack!

Coders are looking for three critical medical decisions making components:

  • Complexity of problems addressed (COPA)
  • Data (tests ordered, consults with specialists, diagnoses)
  • Treatment risk

The details we provide in each category communicate Low, Moderate, or High severity, and the highest of two out of three categories determines the CPT code. If coders can’t find the supporting details in the documentation, they can’t assign the most appropriate code levels, and we don’t get paid the full value of the services we provide.

However, if we standardize documentation on our end, we can make the elusive needle easier to find on the billing side, and in the process avoid down-coded claims, capture all procedures, minimize underpayments, and increase revenue. The goal is to consistently provide COPA, data, and treatment risk in every chart. Anything else is extra, or “lagniappe” as we say in Louisiana.

1. Audit your documentation

Begin by assessing where your practice falls on the continuum of variability. Select a sample of recent charts from different physicians and review where and how COPA, data, and treatment risk details are noted. Are they in the same fields across all physicians, or are physicians using their own systems to complete their notes? Is the language consistent for the same clinical findings, or would the clinical descriptions lead coders to reach different conclusions about severity and risk?

You now know at the practice level whether your team is documenting similarly or independently, and you can consider what that means for your RCM vendor. When RCM teams must devote more time, effort, and resources to preparing and submitting claims, your payment cycle gets longer, and the opportunity for errors increases.

2. Correct for Consistency

If your audit uncovers significant variability in your documentation, you need to get your physicians on the same page, literally. Your RCM team can provide best practices for where and how to note COPA, data, and treatment risk so that they are always in the same place and make sense to coders.

Importantly, RCM partners can also help physicians learn the key words and phrases that correspond with CPT coding. Many of those words and phrases changed in 2023 when the American Medical Association rolled out new Evaluation and Management (E/M) guidelines. As I explained in a recent blog post, the new guidelines reduced box-checking and focus instead on our clinical judgment and decision-making. Physicians who are still documenting under the old rules of engagement are likely providing very little of the information now used to determine reimbursement.

3. Update Templates

If possible, consider working with your health system or facility to adjust the documentation templates within the electronic health record. While the upfront approval process may be tedious, streamlined templates will ultimately make documentation easier at the point of care.

If a template overhaul is not an option, practices can create their own templated verbiage to cut and paste the words and phrases everyone aligned to during the consistency phase.

The Upside

While you’re in the weeds with documentation improvements, don’t lose sight of the project’s higher purpose: better care. When physicians are fairly compensated for their services, they are less stressed, more patient, and they provide better care to the communities they serve.

One of my primary goals as a medical director was to maintain this equilibrium for my practice. It became clear to me that the way to accomplish it was to look under the hood on the RCM side. In doing so, I saw clearly that bridging the two sides—forming a productive partnership with our RCM teams—gives us a path forward to improve not only reimbursement but also patient care.

Introducing the Doc to Doc Blog Series

Ventra Health brings decades of experience both in revenue cycle management and within the clinical specialties of our clients. Dr. Mark Laperouse is pleased to bring you a thought leadership series which draws from his clinical experience as an Emergency Medicine physician and the billing and coding expertise within Ventra. Stay tuned for the next installment of the “Doc to Doc Blog” and catch up on all published posts below.

  • Doc to Doc Series: Improve Reimbursement by Standardizing Physician Documentation

  • Doc to Doc Series: What’s in your pocket at the end of an ED shift?

About the Author

Mark Laperouse, MD is Medical Director Emergency Services at Our Lady of the Lake Hospital in Baton Rouge, LA, and Chief Medical Officer – Emergency Medical Services at Professional Emergency Physicians of Baton Rouge. He is a Strategic Advisor to Ventra Health in Emergency Medicine.