Scribes in the ER

[thegenius]

Why are you doing those things?
Reading prior notes just gets you one point in the same column as ordering a test does. If you've ordered 3 tests and interpreted an x-ray, you're already a lvl 5 in that column. If you admit the patient, you're a lvl 5 in the 3rd column as well and you're done. If you're discharging them, just write an Rx for anything and now that column is a lvl 4 which is a reasonable chart lvl for a DC. Or click the button that says "I considered admitting them but didn't because xxx, e.g. low heart score and negative trops" Now you're back to a lvl 5 in that column and overall as well. No record review or old lab review required.

TL;DR: reviewing old records/labs is literally only useful for the patient whom you are not ordering any tests on.

Correct. That's about 20% of my patients. There are numerous chief complaints that don't require any labs or imaging like rashes, coughs, pediatric everything, URIs, dental pain,

it's a lot of what was written above by the prior poster. Routine dental pain is probably low COPA, low DATA, and moderate RISK for their needless Rx. So you either need to pump up the COPA or DATA column to get the 99284.

i find that you either have to consider lying about how bad their presenting complaint is (COPA) or start looking at their data more.

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[TooMuchResearch]

Why are you doing those things?
Reading prior notes just gets you one point in the same column as ordering a test does. If you've ordered 3 tests and interpreted an x-ray, you're already a lvl 5 in that column. If you admit the patient, you're a lvl 5 in the 3rd column as well and you're done. If you're discharging them, just write an Rx for anything and now that column is a lvl 4 which is a reasonable chart lvl for a DC. Or click the button that says "I considered admitting them but didn't because xxx, e.g. low heart score and negative trops" Now you're back to a lvl 5 in that column and overall as well. No record review or old lab review required.

TL;DR: reviewing old records/labs is literally only useful for the patient whom you are not ordering any tests on.

Hmm I think I need to review the old crappily written guidelines on this.

 

[HemorrhagicShock]

Hmm I think I need to review the old crappily written guidelines on this.

They're so nebulous. I've studied them front to back, and I still have more questions than answers.

And don't even get me started on asking coders. Two different coders will give nearly opposite answers to the same exact question that I ask.

 

[RustedFox]

I'm fairly new to dragon and had no idea this was a thing. Thank you!

It's not Dragon, it's M-Modal; but you can set it up however you like.
I used "ZIP", as it's one-syllable and a word that I would otherwise rarely use.

 

[RustedFox]

Correct. That's about 20% of my patients. There are numerous chief complaints that don't require any labs or imaging like rashes, coughs, pediatric everything, URIs, dental pain,

it's a lot of what was written above by the prior poster. Routine dental pain is probably low COPA, low DATA, and moderate RISK for their needless Rx. So you either need to pump up the COPA or DATA column to get the 99284.

i find that you either have to consider lying about how bad their presenting complaint is (COPA) or start looking at their data more.

"ZIP-THREE-PLUS-RECORDS" = "Patient's recent inpatient history was reviewed, including at least three separate inpatient records - to allow for a more comprehensive understanding of the patient's course of care to date."

It takes 10 seconds or so to look at an IM note, pulm note, and some other useless note to see that the patient has VA-associated risk factors and won't quit smoking. You don't have to import the data from those notes.

 

[HemorrhagicShock]

"ZIP-THREE-PLUS-RECORDS" = "Patient's recent inpatient history was reviewed, including at least three separate inpatient records - to allow for a more comprehensive understanding of the patient's course of care to date."

It takes 10 seconds or so to look at an IM note, pulm note, and some other useless note to see that the patient has VA-associated risk factors and won't quit smoking. You don't have to import the data from those notes.

This is exactly what I'm talking about.

I tried to do exactly this, but our coders told me that without specific information that's individualized for that patient, they couldn't accept a blanket template statement like this.

Just goes to show that I don't think anybody actually knows the rules.

 

[TooMuchResearch]

It's not Dragon, it's M-Modal; but you can set it up however you like.
I used "ZIP", as it's one-syllable and a word that I would otherwise rarely use.

Good luck with the occasional penis stuck in zipper injury. Impossible chart to write.

 

[RustedFox]

Good luck with the occasional penis stuck in zipper injury. Impossible chart to write.

Already templated.
"ZIP D!CK STUCK".

 

[TooMuchResearch]

They're so nebulous. I've studied them front to back, and I still have more questions than answers.

And don't even get me started on asking coders. Two different coders will give nearly opposite answers to the same exact question that I ask.

Our outsourced coding company has not been helpful.

 

[TooMuchResearch]

Already templated.
"ZIP D!CK STUCK".

That's amazing.

 

[maxxor]

I'm fairly new to dragon and had no idea this was a thing. Thank you!

Powerscribe / Dragon uses other default keywords.

My personal one is a one-syllable phrase which is not even a word so I don’t accidentally trigger the macro insertion / command functionality.

 

[dozitgetchahi]

They're so nebulous. I've studied them front to back, and I still have more questions than answers.

And don't even get me started on asking coders. Two different coders will give nearly opposite answers to the same exact question that I ask.

Agreed.

I have seen two coders totally disagree on a wide variety of things. Every single time I switch jobs, I have the coders show up and tell me I’m “doing everything wrong” with how I’m coding and documenting, and show me “the right way”. Except that “the right way” seems to completely change with each set of coders you talk to.

I agree that on some level, I’m not sure anyone actually knows the rules. Or at least, everyone makes up rules as they go along.

 

[HemorrhagicShock]

Agreed.

I have seen two coders totally disagree on a wide variety of things. Every single time I switch jobs, I have the coders show up and tell me I’m “doing everything wrong” with how I’m coding and documenting, and show me “the right way”. Except that “the right way” seems to completely change with each set of coders you talk to.

I agree that on some level, I’m not sure anyone actually knows the rules. Or at least, everyone makes up rules as they go along.

The best is when two INTERNAL coders working on the SAME TEAM go at each other over the same question.

Truly a broken system...

 

[BoardingDoc]

Correct. That's about 20% of my patients. There are numerous chief complaints that don't require any labs or imaging like rashes, coughs, pediatric everything, URIs, dental pain,

it's a lot of what was written above by the prior poster. Routine dental pain is probably low COPA, low DATA, and moderate RISK for their needless Rx. So you either need to pump up the COPA or DATA column to get the 99284.

i find that you either have to consider lying about how bad their presenting complaint is (COPA) or start looking at their data more.

1: look at their med fill hx (usually a single click) and talk about what meds they're on. 2: check the pmp and document no concerning prescribing patterns (also usually a one click thing). 3: say you considered labs but they aren't needed due to no systemic symptoms. Now you're a lvl 4 in that column for about 30sec to 1 min of effort. Write an rx for anything and you have a lvl 4 chart.

That's my go to method for those patients.

 

[sloh]

This is exactly what I'm talking about.

I tried to do exactly this, but our coders told me that without specific information that's individualized for that patient, they couldn't accept a blanket template statement like this.

Just goes to show that I don't think anybody actually knows the rules.

Can anyone give more feedback on what is kosher? Can a blanket template count?

 

[thegenius]

This is exactly what I'm talking about.

I tried to do exactly this, but our coders told me that without specific information that's individualized for that patient, they couldn't accept a blanket template statement like this.

Just goes to show that I don't think anybody actually knows the rules.

We have lots of problems with our coders and billers too. The disdain runs deep. Lots of the tricks listed above have been rebuked.

Part of the problem is our Power Chart version from Cerner is just so awful that it's really painful to quickly move around. Things literally can't be done in 30 seconds.

Anyway, there are lots of ways to get points in Data, whether you look at old charts, old labs, consider labs but not do them, etc.

 

[HemorrhagicShock]

Can anyone give more feedback on what is kosher? Can a blanket template count?

How does it work in your specialty? I gather your PMR from what I've seen you post.

What I gather is that this is EXTREMELY individual down to the specific contractual relationship between the payor and the provider.

For example, two patients come into the ED, both with low acuity chest pain, they're ruled out and discharged. One is Anthem Blue Cross; the other is Humana (both contracted individually and locally with the ED provider group at whatever said hospital).

These two exact same charts (assuming they're written up the same way, same workup etc) could result in different levels of collection simply under whatever black box internal processes those two insurers have.

Thus, it's an arms race for the providers to constantly try to figure out and keep up with what is an acceptable templated documentation approach. I fully expect AIs and LLMs to help out with figuring this out (already, there are tons of coding companies that are doing exactly this; I'm not sure how successful they are).

Kind of BS that this is how the game works, but the only way to win is to play.

 

[sloh]

How does it work in your specialty? I gather your PMR from what I've seen you post.

What I gather is that this is EXTREMELY individual down to the specific contractual relationship between the payor and the provider.

I agree with you. I see mostly medicare patients and they tend to be way more lenient compared to commercial insurers. I haven't gotten to the point of using blanket templates for the data section for SNF patients though. I would if it was kosher to save more time bc a sizable number of these SNF patients are admitted to the hospital for psych, low grade bonks, etc. where the CBC and BMP are 99.99% of the time normal.

 

[Apollyon]

I agree with you. I see mostly medicare patients and they tend to be way more lenient compared to commercial insurers. I haven't gotten to the point of using blanket templates for the data section for SNF patients though. I would if it was kosher to save more time bc a sizable number of these SNF patients are admitted to the hospital for psych, low grade bonks, etc. where the CBC and BMP are 99.99% of the time normal.

That reminded me of something out of the blue from about 10 years ago, totally random. A pt I thought had uremic breath. So, I labbed him. Result? Severe...halitosis!! Swing and a miss by me!

 

[HemorrhagicShock]

I agree with you. I see mostly medicare patients and they tend to be way more lenient compared to commercial insurers. I haven't gotten to the point of using blanket templates for the data section for SNF patients though. I would if it was kosher to save more time bc a sizable number of these SNF patients are admitted to the hospital for psych, low grade bonks, etc. where the CBC and BMP are 99.99% of the time normal.

How long do you think the SNF game will continue to be lucrative?

The unfortunate part about these little CMS niches where you can volume grind is that they get tamped out pretty quickly, which is silly because some of the times they're actually high value services that help out a lot of patients