If we have to live with the rules the insurers make,

we might as well learn to work with the rules

Learning PointsBeing an excellent Family Physician depends more

on having the right tools than having the best knowledge

Documentation requirements were established with no evidence that they are equitable or achieve quality

Thinking about documentation requirements after the visit ensures that you will be undercompensated for your care

Some documentation rules can be used to prompt you to structure your care so that quality improves

The quality chasm between primary care and subspecialists

“Why would you waste your career on Family Practice?” the Dean

“You won the battle but lost the war. It’s not what we know, it’s what we do!” George T. Wolff, M.D.

In court, you are held to the same “standard of care” as any other doctor

In order to accomplish this standard, the Patient Centered Medical Home says we need to organize our practices to create this

This presentation talks about how you can organize yourself so you can do your part in creating excellence.

Those with the gold write the rulesIn 1960, GPs were paid 70% of the highest paid

specialty in the USIn 1980, FPs were paid 50% of the highest paid In 2009, FPs are being paid 25% of the highestWe have not learned to “play by the rules!”Barbara Starfield has shown that the best quality

and lowest costs are found in places with the highest ratio of FPs to population

PCMH says we have to learn to work with the rules to achieve demonstrable quality so we can increase FP compensation 50-100%

What are the rules?Patient is new or establishedLocation of the serviceType of serviceHistoryExam Medical Decision Making

Rules are the same regardless of specialtyFPs have regularly underestimated their work

HistoryProblem Focused - PFExpanded Problem Focused – EPFDetailed – DComprehensive - C

Physical Exam Problem Focused - PFExpanded Problem Focused – EPFDetailed – DComprehensive - C

Medical Decision MakingStraight Forward – SFLow Complexity – LCModerate Complexity – MCHigh Complexity – HC

Must have 2 of following 3 componentsProblems – Limits – 1 new problem, 2 minor

problemsData Analysis – Seldom drive MDM in officeRisk – FPs generally under estimate this!

Rational Physician approach to documentation and coding

New Patient – 3/399201 – SF 99202 – SF99203 – LC 99204 – MC 99205 – HC

Established Patient – 2/3 99212 – SF 99213 – LC 99214 – MC 99215 – HC

•Start with Medical Decision Making to choose your service code•Document History, Exam, or Time to support the code

Starting with the end in mindSeparate history by problem(Have staff record history elements physicians

notoriously forget, e.g. date of injury, location of symptoms, severity, & associated S/S) Physician should generally record Radiation, Quality, Context, & Relieving & exacerbating factors

Multiple diagnoses with description of certainty and/or interrelationships – No Naked Diagnoses!

Record all of your plan!

Future LessonsWeek of:

August 17 – Getting the History RightAugust 24 – Documenting PE, Data, & Writing

ScriptsAugust 31 – Assessment & PlanSeptember 14 – An excellent single problem

noteOctober 13 – Documenting Prevention VisitsNovember 3 – Managing Multiple Problem

Visits

This week’s practice focusIs your note clear? I.e. If you had not been in the

room, would you be able to read your note and have a good idea of what the visit was about?

Have you eliminated resolved ambiguity? I.e. The patient often presents with a jumble of concerns that your interview resolves. Have you recorded the jumble or the resolved clarity? (Remember, reality is often ambiguous even after you’ve done your best!)

Is your note succinct? Skilled clinicians only record 10% of information exchanged in a visit. The rest is “chaff” that does not inform.