Erin Galloway (00:00): Welcome to The Missing Ink. The documentation education team strives to bring education in various platforms and is thrilled to be able to add podcasting to that list. Today we are excited to have our first inaugural podcast. I am Erin Galloway on for the Senior Directors and documentation and will be the facilitator for today's podcast. And with me is Dr. Zach Goldman to discuss all things 2023 guideline change related. Dr. Goldman is an envisioned emergency medicine physician in Dallas and is a National medical Director and vice President of Clinical Documentation. Welcome Dr. Goldman. Dr. Zack Goldman (00:32): Thank you so much Aaron. Thanks for allowing me to participate in the inaugural podcast. This is very exciting. It's great to bring information to our envisioned clinicians and colleagues being these different formats. Erin Galloway (00:45): Okay, Dr. Beman, everywhere I turn these days, I'm seeing and hearing about changes in the 2023 evaluation and management guidelines and then apparently it's a big deal. So what's changing and who does this impact? Dr. Zack Goldman (00:58): Okay. Starting January 1st, 2023, the e and m codes, which is the evaluation and management codes, or typically the hospital codes we use will be determined by medical decision making or MDM only to make it a little bit more complicated. Even though medical decision making has always been a factor in assigning an e and m, how medical decision making is determined is also changing. We get the double whammy. This will impact the majority of our envisioned clinicians to some degree. The largest impacts are in those in the hospitalist service such as hm, OB peds, our ED clinicians, and our surgeons. Erin Galloway (01:43): Interesting. So now that coding is based solely on medical decision making, that means you don't have to document a history and physical exam anymore. Right. Dr. Zack Goldman (01:53): I knew that was gonna be the question you were gonna ask. Well actually you still need to document a medically appropriate history and physical exam. This is left to the discretion of the clinician seeing the patient. That said, it's really important to understand that clinical documentation is impactful on several other areas outside simply assigning an ENM level of service. The history and physical examine assists in accurately capturing the quality severity and intensity that patient in front of them. The documentation paints a picture of the clinical encounter and captures a patient's condition and is the basis for the clinician's thought process. These elements also substantiate the medical decision making help capture quality and mitigate risk. So long answer is you still need to document an appropriate history and physical exam. Erin Galloway (02:47): Okay, gotcha. Now that's a lot of information on mdm so can you kind of break that down and tell, tell us what makes up medical decision making? Dr. Zack Goldman (02:56): Sure, and this is probably the most boring part of this conversation, but medical decision making is broken down into three separate components and this has always been the case. Their titles may have changed a little bit, but more importantly what makes them up has changed and that would be a lot more of maybe what we discussed later today. The three components are number and complexity of problems addressed during that specific encounter. Two, a amount complexity of data to be reviewed and analyzed. And three, the risk of morbidity, mortality, lots of words but three different sections. And to assign a level of medical decision making, two of the three have to marry up to assign that final e and m level. Erin Galloway (03:43): So do you have any pointers on how our clinicians can clearly paint that picture of the complexity and severity of the patient that's right in front of them on that specific date of service? Dr. Zack Goldman (03:53): Yeah, and I love what you just said on in front of them on that specific date of service. So we're talking about every unique encounter and one of the things we want to do is focus on the key words that the patient gives us regarding their condition. Is it acute? Is it chronic? Is it mild, moderate, severe? Is it an exacerbation, is it a severe exacerbation? These words help paint the picture, tell the story of what's going on. There are other things too. We can use the diagnosis itself. There is a difference between a patient who has say anemia and severe anemia or they have moderate acidosis. Additionally documenting the differential or the rule out diagnoses of what conditions you may be worried about or considered. And those that you have actually ruled out. Paint a picture of just how sick the patient in front of you is, or more importantly could be. (04:53): Don't forget to include any chronic conditions that may impact the patient's condition and your decision making. Many patients have a specific clinical complaint, but they also oftentimes have other medical conditions such as hypertension, diabetes, or electrolyte abnormalities, excuse me, impacting their presentation. It must be clear that these conditions were addressed that day and not just listed in the past medical or family history. Finally, like what we talk about with IC 10 when it first came out, we want to document the most specific and appropriate diagnosis we can. One of the most common examples I always like to think about is shock, especially sepsis and sepsis related to shock. There is a specific difference between a patient who presents with say sepsis or severe sepsis or septic shock or has pneumonia but actually has respiratory failure and hypoxic respiratory failure secondary to pneumonia. We are clearly going to treat the patient in front of us based on their conditions, but these specifics help capture that condition more accurately. Erin Galloway (06:04): I'd like to back up to one of the first things that you mentioned here and you stated this unique encounter. Can you tell me a little bit more about what you mean by that? Dr. Zack Goldman (06:14): Yeah, I think this is a really unique and a specific call out that what we need to do is be able to paint the picture of what happens on that specific day and all the documentation that we're talking about should capture and support the complexity of care delivered and provided on that day. For example, what problems were addressed, what medications were ordered, what diagno diagnostics were done on that particular day. When patients are in the hospital for more than one day, sometimes when I review charts it can be really difficult to determine on what exactly happened on that date of service. I can't stress this enough, especially on subsequent visits. The documentation for that date of service should stand alone, paint a picture of what was done that day, what was the clinical concern that day. I think you hear me reiterating and reiterating that term that day. But I think that is what we are trying to capture. Can we paint a picture of the care we delivered to that patient and once again on that specific day? Erin Galloway (07:30): Got it. So I think what you're saying is on that day, right, Dr. Zack Goldman (07:33): Yes, that day. Erin Galloway (07:35): Got it. Okay. So next question. When documenting data, we know most of these EHRs automatically bring in your labs and other diagnostic imaging orders. What are other items that our clinicians should be aware of that are considered part of data? Dr. Zack Goldman (07:52): Yeah, I think that's a great question and obviously as you said, it makes up one of the three components of medical decision making. So I think I wanna start with the first part. Sometimes I think we assume that the EHR brings in that information and I think we wanna make sure that that information actually is captured in our medical record and not somewhere else. If it is captured in the medical record, the tests you order, the blood work order or the diagnostics you order, then yes, that'd be great. Populate your chart if it doesn't, it's really important that again, on those unique encounters, that information is part of your note and you're capturing it explicitly. Other areas to consider related to, you know, that second element of medical decision making and the data section is did you need to in get information from an independent historian? That's pretty straightforward. If the clinician needed history from another historian, you need to document who the historian is and why you needed the information. For example, the patient's nonverbal, so history was obtained from a parent or the patient has severe dementia, so you had to get the information from a family member. Again, the key is capturing the who and the why. Erin Galloway (09:09): So quick question on that. Many times we know clinicians have to use an interpreter to assist with taking care of a patient. So does an interpreter count as an independent historian? Dr. Zack Goldman (09:20): Yeah, great question. And the simple answer is no interpreters don't count as an independent historian as they relay the information that the patient has given you, they're not actually providing the history themselves. Erin Galloway (09:32): Okay. So the next question is, I know the guidelines also discuss reviewing external notes. Do the clinicians need to specifically state external notes reviewed? Dr. Zack Goldman (09:45): Yeah, I think that's a great question. And it's a little bit of a matter of semantics. Let's first describe what an external note is. By definition an external note would be a note outside of your local specific group and specialty. So I think okay, that makes sense. But in reality I think the best practice is yes to comment on external note if you can, but in reality document the work that you've done. So if you review an old note, document what type of notes you reviewed and what your findings were related to that note,
