28 years ago, the die was cast for how emergency department encounters were documented. Since then, we’ve had note bloat, click fatigue, and too much attention placed on things that really didn’t matter. All of that is slated to change in 2023 with dramatic new documentation guidelines (that today’s guest calls ‘refreshing’) are implemented. When was the last time you heard the word ‘refreshing’ used when it came to charting? And a massive thank you and hat tip to my friend Matt DeLaney who now runs ERcast – he was the first to alert us to these guidelines and interviewed Jason when they were first announced.
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Guest bio: Jason Adler, MD is a clinical assistant professor of emergency medicine at the University of Maryland where he is also the director of compliance and reimbursement. He is also the vice president of acute care solutions at LogixHealth.
Mentioned in this episode: The Awake and Aware Physician conference sponsored by Wild Health. Jan 13-15 Sedona Arizona. Use the code CONSCIOUSPHYSICIAN for 15% off (that’s 15% off the whole package – lodging, meals, the course)
History and physical documentation are now at your discretion;
- The history and exam sections will no longer be used to score the chart.
- This means that all that time spent on making sure you’ve got enough elements in the history, that you’ve hit the right points on exam, and that you don’t forget family history… all of that… is done. Going forward, if it’s important, write it. If it’s not, skip it. It’s not required as far as the guidelines are concerned.
“The nature and extent of the history and/or physical examination is determined by the treating physician reporting the service.” 2023 CPT E/M Descriptors and Guidelines
Heavy value is placed on cognitive work and medical decision making;
- What is most of your high value time spent in patient care? Thinking! You are thinking through what is going on, the possibilities and what to do about those possibilities. Your cognitive work is the real core of the true work that you do. And this is what is heavily weighted and the new guidelines.
- Your medical decision-making should demonstrate the complexity of care. This includes your differential diagnosis, studies ordered and not ordered, patient comorbidities which can add complexity to the situation.
History from a non-patient source is valued in these guidelines;
- So much information in the emergency department is obtained from somewhere or someone other than the patient. This is part of your normal workflow. As long as what you learned is integrated into the care of the patient, document it.
- Examples include
- Information from a non-patient historian such as EMS, law enforcement, caregivers, and parents.
- Conversations with Consultants, referring clinicians, Social Work, case management
- Review of non ED record review including inpatient notes, outpatient nose, old studies.
Ordering a test is equally valued as not ordering a test;
- The 1995 guidelines awarded credits and valued active ordering of studies or images. Under the new guidelines, you will get the same credit if you don’t order a test so long as you provide a rationale and thought process as to how you got there
“Ordering a test may include those considered, but not selected after shared decision making. A patient may request diagnostic imaging that is not necessary for their condition. Discussion of the lack of benefit may be required.” 2023 CPT E/M Descriptors and Guidelines
Consideration of escalation or deescalation of care;
- This includes complexity of problems addressed, data, and risk.
- Escalation of care or hospitalization is considered high risk and highly valued in these guidelines.
- Consideration of admission is also valued.
- There are some patients where you’re just not sure.
- Example. Renal colic that may or may not improve with ED management
- In a patient with a symptomatic kidney stone, you will make the decision of admit/discharge home based upon whether they can tolerate pain or tolerate fluid. You might be considering admission until you realize they can now tolerate pain, are no longer vomiting and are able to ambulate.
- You have good follow ups dialed in, return instructions discussed, and they’re now safe for discharge.
- Consideration of admission is just highly valued on these guidelines and declaring it in a way that you considered it will be valued and acknowledged.
- The opposite is also true with deescalation of care
- Example: non operative brain bleed
- If a patient has a catastrophic brain injury, there may be a conversation with a neurosurgeon not to transfer to a tertiary referral center and take a palliative care approach. That is a de-escalation of care.
- Example: Using the HEART Score.
- You have a conversation of shared decision making. Is the patient going to stay in the hospital or go home? Are you and the patient going to escalate deescalate care?
“This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.” 2023 CPT E/M Descriptors and Guidelines
In addition to documenting your shared-decision making conversations, your MDM should include;
▪ Differential diagnoses based on your evaluation
▪ Rationale of including or excluding diagnoses
▪ Mention of comorbidities, which add complexity to risk stratification and shows the value of your work
▪ The addressing of secondary complaints, abnormal labs, or abnormal vital sign
Population health: Stable means something different when it comes to documentation;
“‘Stable’ for the purposes of categorizing comorbidities in the MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.” -Jason Adler
- How does this relate to population health? Let’s use hypertension as an example.
- A patient presents with asymptomatic elevated blood pressure. Even though they are not ‘unstable’ from an emergency management standpoint, this condition would be defined as unstable in the new guidelines because it has not met the goal of care.
- The patient in front of you may not need acute treatment in the ED beyond a conversation and encouraging follow-up. That conversation, however, is valued in the new guidelines under the population health aspect.
“If we could identify asymptomatic hypertension, a problem that could potentially have long-term morbidity, and in some cases mortality, and simply make a referral… that could really change lives.” -Jason Adler
Social determinants of health;
- Economic and social conditions that influence the health of people and their communities
- Problems related to:
- Housing instability and economic circumstance
- Low income or unemployment
- Insufficient social insurance
- Lack of primary support group
- Living in a residential institution
- Lack of transportation
Acknowledging social determinants of Health in your decision-making is valued in the guidelines;
- Some of Jason’s examples
- If you have ever given a patient an inhaler instead of a neb with the intent of having them keep it because they’re not able to fill it as they’re so expensive –that patient may have a social determinant of health.
- If your hospital has an arrangement with a rideshare organization where you help people get home using Uber or Lyft.
- if you have a process in place whereby you give a patient antibiotics to go or a viral pack to go, there might be a reason for that.
There is a heightened emphasis of independent interpretations of separately billable procedures (EKGs, X-ray, CT, U/S);
- If you are going to make a treatment decision based on interpretation of a study, there is value in documenting that it is your interpretation and in doing so, that is also credited within the guidelines.
Jason’s take home points;
▪ The history and exam will no longer be used to score the chart ▪ Medical decision making will now drive code selection.
▪ Heightened emphasis on shared decision making and social determinants of health.
▪ Document discussions with patients, considerations of testing, treating, or escalation of care.
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