The Draft Documentation Guidelines: Unloading the Last Straw
Fam Pract Manag. 1999 Sep;06(8):9.
While I suppose a good cover story shouldn't elicit a groan from readers, we think the documentation guidelines are important enough to you that they merit cover-story prominence. If the final guidelines look anything like the draft version available now, the good news is that they're simpler than they were the last time around. The bad news, of course, is that they're still relatively complicated and still require counting of elements.
OK. I hear you: The bad news is that they still exist at all. I agree. Your life is complicated enough. But the problem is deeper (and older) than the guidelines. Once it was established that a level-III visit was worth so much, for instance, the question of what constitutes a level-III visit became financially significant. The guidelines are just an attempt to answer such questions objectively.
No, the guidelines are a fact of life now, and they are likely to remain so into the foreseeable future. It's not profitable to think how much better practice would be without them. The more helpful question is how best to practice with them. And the “new framework” introduced in Leigh Ann Backer's article may even make that question easier to answer.
The easiest guidelines to live with would be ones you don't even need to think about from one week to the next. If you could just document conscientiously for all the right reasons (well, for all the right reasons plus concern about potential malpractice suits, but that's another battle) and be confident that your documentation would support the right code, that wouldn't be so bad, would it? That seems to be the ideal that the CPT Editorial Panel has had in mind from the beginning. The new framework seems to have gotten much closer to that ideal than the 1997 guidelines did.
Of course, we're still far from the ideal in that someone still needs to interpret what you write to deduce a CPT code from it, and there's still the possibility that the code you check off on the superbill may not be the one your documentation supports. That seems to be the irreducible minimum of hassle involved in having guidelines, and it will be a pain at least until your records are computerized and your computer finally gets smart enough to read your note and assign a code to each visit.
In the meantime, unfortunately, the challenge will be to find ways of living with, and minimizing, the hassle — training yourself to make your notes as complete as possible, verifying the calibration of your seat-of-the-pants coding sense, adopting checklists and other tools designed to make documentation easier, etc. As with previous versions of the guidelines, FPM will help. Watch for articles on the topic next year as we get close to the implementation date. And try to take a positive view: If the 1997 guidelines were the last straw, at least they'll be gone when the new framework kicks in; that ought to lighten your load noticeably.
Copyright © 1999 by the American Academy of Family Physicians.
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