We've Always Done It This Way and Other Challenges in Education

October 19th, 2018 - BC Advantage
Categories:   Compliance   Documentation Guidelines   Practice Management   Audits/Auditing  
1 Vote - Sign in to vote or comment.

As coders, auditors, and compliance professionals, we are the provider's advocates in closing the gap between what is medically necessary and what is required for documentation. Sometimes that places us in the role where we need to save our clinicians from themselves, and the patterns they have fallen into.

"Other providers would know that meant...."

This is one sentiment that we all have had at one time, or another. If it comes easy to us, or if we could learn something, human nature is to presume it is shared knowledge across all people of the same position. Many providers presume that the documentation makes it clear to any other provider, because they hold the assumption of shared knowledge. Unfortunately, this is an assumption that could be life-threatening.

The reason the documentation needs to be clear, is not just for supporting the medical necessity of an encounter, but also to show other providers what the thoughts, concerns, and plan are for the patient. If every provider would instinctively understand lab values, and imaging findings, there would be no need for specialty consultations.

"Dr. XYZ does it that way, and I don't see them getting in trouble"

"We've always done it that way"

"If it gets paid, why does it matter"

We have heard it all, across the nation. As a compliance educator, there are few things more challenging than the roadblocks clinicians throw up to prevent themselves from feeling like they have failed at something. They are constantly having to prove themselves as a student, a resident, a clinician, in journals, in specialized research, and the list goes on. The very act of getting into medical school, and getting their license is such an intense process that the idea of failing, even at something as subjective as coding, creates an instant response of self-preservation.

It is our job to show them that it is not that they have failed, but rather that the documentation has gaps that we can help to fill in. As their advocate, we need to show them that it is less about the score of the audit, but the opportunities that have been identified. A provider may fail at 100%, but that doesn't mean that they have deliberately committed fraud, or that they don't know anything about coding. It simply means that we have areas to help shift the focus and that we support them in capturing the work they do.

If you walk into an education session thinking that they were wrong, or doing it on purpose, or that you know more than them, they will never feel safe in learning from you. In thousands of reviews, there have only been a select few that have deliberately coded things that they knew were not supported. That leaves the majority of the providers that really are doing their best. It is a process issue, and we need to help them to understand that it's not their failure. When a provider does not see the purpose of the documentation requirements, they have a hard time accepting that it needs to be captured.

We are their advocate, not their adversary. 


This Week's Audit Tip Written By:  

Omega Renne, CPC CPCO, CPMA, CEMC, CIMC

Omega is a compliance consultant for our parent organization, DoctorsManagement.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association