Going with the Flow of Traffic
There is nothing that ruins a great road trip faster than a speeding ticket. Yes, I saw the sign that said 70 mph limit. Yes, I might have maybe possibly been going slightly over the leeway of 8 miles per hour. But I was sandwiched between two semis and I was trying to pass so that I would have better visibility and avoid the billboard effect. I’m sure I wasn’t exceeding the ‘acceptable’ zone for more than a few minutes. I really wasn’t even aware of the speed because I was just keeping up with the flow of traffic. Sigh … here’s my license and registration officer.
That’s the thing about rules. Everyone knows them and everyone knows that the rules are not followed by anyone 100% of the time. Some rules are treated more like suggestions, best practice if you will. The reasons are endless and for the most part seem harmless until you are the one on the side of the road waiting for your fate. You calculate the # of points this may add to your license or if this will have any impact on your insurance rates. Can it really be considered reckless if you are 15 over the posted limit?!
Can it really be non-compliant if your EMR is the reason that all of your orders are submitted with a diagnosis code instead of a relevant clinical statement by the treating physician? After all, I’m sure that “other unspecified disease of the digestive tract” is extremely helpful in the care of the patient. The AHA has offered guidance in several issues of Coding Clinic for ICD-10-CM that it is insufficient to use just the diagnosis code and description in place of a clinical statement. But every electronic health record is set up that way, I’m just going with the flow of traffic.
Is it really non-complaint if you assign a code for the relevant findings and/or reason for the exam but leave the context in the medical record? The ICD10 guidelines (there are those rules again) state that all relevant comorbidities and concurrent conditions should be assigned if they impact the medical decision making for that encounter. Is it relevant that the patient with abdominal pain has Crohn’s disease? Does the fact that the patient is on dialysis impact your decision to use contrast? You know the extra resources and limitations in any scan when the patient’s BMI is on the higher end, but was it worth the time to also communicate that to the payor who is using your diagnosis data for future complexity scores? I get it. That takes extra time and you really need to close those reports by month end without overtime.
There is always a risk in not following posted road signs – whether from the DOT or CMS. As you mentally balance the risk against the consequences think of one more perspective – the clinicians.
For months (if not years) the clinicians have been trained against their will to improve clinical documentation. Add the details. Tell the story. And they have. Clinical histories include the details about the underlying malignancies and the secondary malignancies and the fact the patient smokes or is 27 with a BMI of 52. The clinical history clarifies that the fall was on the same level vs. off the porch or that the swelling is the result of no known injury. It may be a good idea to start rehearsing the story for why that information wasn’t submitted to the payor and why the practice cannot obtain frequency information to highlight target audiences with specific services as required by the clinical practice improvements in MACRA. I’m sure it will be a good one. But will any of the reasons get you off with just a warning if CMS decides to enforce that clearly posted limit?