Measuring, Documenting Care Vital to Success With New Payment Models

September 21, 2012 08:15 pm Matt Brown

DeAnna Vaughn, M.D., practices family medicine in tiny Neodesha, Kan., and uses technology to help her document the care her patients receive.

It seems clear that payment for health care services in the United States is transitioning from the fee-for-service model into something more collaborative. Exactly what shape that "something" will take remains in doubt, but regardless of which model or models the industry settles on, physicians will have to measure and document the care they give if they want to get paid.

According to Bruce Bagley, M.D., medical director of quality improvement for both the AAFP and its wholly owned practice redesign subsidiary TransforMED, the combination of cost and quality -- designed to ensure better care and healthier patients
-- is essentially about value-based purchasing.

"The system for measuring and documenting care we are transitioning to is designed, in theory, to drive quality," says Bagley. "It is about getting the most value for the patient and offering up care that's going to help him or her be better -- have a better, healthier quality of life -- rather than just treating an illness when it crops up.

story highlights

  • The system for measuring and documenting care to which medicine is transitioning is designed to drive quality.
  • Physicians will have to measure and document the care they give if they want to get paid for that care.
  • The transition from the World Health Organization's ICD-9 codes to ICD-10 is big, and family physicians need to be prepared.

"Value for patients is about higher quality for lower cost through improved efficiency and reliability. In the past, we in the medical profession have not had very good ways to measure the quality of the care we provide, but now, with nationally endorsed clinical performance measures, this is changing."

But change can be hard, especially when it involves medical record documentation and the World Health Organization's international classification of diseases (ICD) list.

Debra Seyfried, an AAFP coding and compliance strategist, explains that CMS' requirements -- record pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, examinations, tests, treatments, and outcomes -- can be taxing, but they do serve a greater purpose.

She says CMS's 1995 documentation guidelines for evaluation and management services(, along with the 1997 guidelines(, paint a framework within which health professionals can better track -- and be paid for -- the examinations they perform. Services are rated based on the following elements:

  • chief complaint;
  • history of present illness;
  • review of systems; and
  • patient's personal, family and/or social history.

The more specific a physician is in his or her notes, the better he or she will be paid.

"That is just part of the evaluation and management guidelines -- what needs to be in their documentation," Seyfried says. "Too often, when they are making notes about the chief complaint, doctors put 'Here for follow-up' and that doesn't qualify. They need to write 'Here for follow-up of sore throat,' because there is a code for that."

Getting comfortable with documenting these specifics is imperative, says Kent Moore, AAFP's manager of health care financing and delivery systems. He explains that the 1997 guidelines allow a physician to get credit for examining multiple aspects of a single organ system. The 1995 guidelines, on the other hand, allowed credit for only a single exam, no matter how much was documented about a patient's cardiovascular system, for example.

"Under the '97 guidelines, if you hit the right points in that documentation, you can achieve the same number of exams as if you documented six or seven systems under the '95 guidelines," Moore says. "So all of this assumes that the member understands that documentation is the key to getting paid, and that he or she understands the basics of coding for evaluation and management services, which is the bread and butter of what family physicians do. The rule of thumb in medicine today is simple: If you didn't document it, it didn't happen."

This will be especially important as the medical industry gets ready to add thousands of codes in the transition from the current ICD-9 list to ICD-10 on Oct. 1, 2014. When that happens, physicians will go from dealing with more than 14,000 three- to five-digit codes to more than 68,000 three- to seven-digit codes.

"Doctors will not only have to be cognizant of what they're coding in terms of what they do, but also the reason they are doing it in terms of diagnosis coding," Moore says. "And ICD-10 is only going to increase that."

"We are going to have to know more and more specifics," Seyfried says. "How it happened, where (the patient) was when it happened, who caused it to happen, etc. And the doctors are going to have to be prepared for this."

Seyfried notes that the Academy offers many avenues to help members get ready for ICD-10, including online courses, a series of training articles in Family Practice Management (Members/Subscribers Only) and CME sessions at the upcoming AAFP Scientific Assembly.

"Doctors won't be able to just rely on coders to handle it," she says. "We can't code what's not in the dictation. So if they don't understand the how and why behind this, their coder will be standing around in the hall when they are in there amending the notes."