Physician Efficiency in Documentation Series

With the 2021 changes to E/M and the subsequent audit focus shift to MDM and medical necessity, Dr. James Dunnick believes there needs to be a focus on the speed/efficiency of documentation that will allow the provider to have more clinical time and less clerical time with each patient. By improving office patient flow, each clinic can see more patients per shift. This will increase patient satisfaction by increasing patient access times. Economics will improve with a higher patient volume by both the patients seen and the subsequent increase in needed ancillary testing. DRG grouping for severity of illness metrics will come into play and the metrics of quality and utilization must be documented for correct credit to be received.

Suggested Audience: Physicians, coders, and HIM directors

Session 1 - The Needs and Supervision of an Electronic Office

In this first session of the Physician Efficiency in Documentation series, Dr. James Dunnick discusses the critical components of an electronic office. Board certified not only in internal medicine and cardiology but also as a certified professional coder, Dr. Dunnick thoroughly covers how medical office personnel, chart preparation, liability from poor provider documentation, and online patient communication contribute to efficiency in physician documentation. 

Upon completion of this presentation, you should be able to:

• Describe changing medical office personnel needs.
• Explain how to improve correct chart preparation.
• Recall the manager’s liability exposure from poor provider documentation.
• Recognize and improve your online patient communication.

Session 2 - Efficiency, Speed, Accuracy, and Better Economics Part 1

In this second session of the Physician Efficiency in Documentation series, Dr. James Dunnick continues his discussion of the critical components of an electronic office. He covers the new E/M rules, the benefits of using ICD-10 CM correctly, and shares the negatives providers can face for non-compliance.

Upon completion of this presentation, you should be able to:

• Recall the payer purpose behind ICD 10 and Evaluation and Management (E/M).
• Identify when, when not, and how to apply the new E/M rules.
• Describe the provider benefit of using ICD 10 CM correctly.
• List the individual negatives for providers in non-compliance.

Session 3 - Efficiency, Speed, Accuracy, and Better Economics Part 2

In the final session of the Physician Efficiency in Documentation Series, Dr. Dunnick concludes the series with part two of his discussion on Efficiency, Speed, Accuracy, and Better Economics. He provides several clinical coding examples with E/M calculations to demonstrate how to correctly use ICD-10 CM to show a patient's severity of illness. 

Upon completion of this presentation, you should be able to:

• Recall clinical examples to reinforce topics described in Part 1. 
• Discuss E/M calculations and the documentation needs of the different E/M levels.
• Describe the payers’ data recording of providers. 
• Identify how to use ICD 10 CM to correctly show a patient's severity of illness.