Telling a Story

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Medical decision making process is often overlooked by “click-box” approach to record keeping.

In many cases, emergency physicians have become “clickologists,” says Dr. Paul Orcutt, CEO of PhyCon, Inc, an emergency physician billing company located in Oklahoma City, Oklahoma.

He’s referring, of course, to the way many EMRs have tied up emergency physicians with a host of pull down boxes to detail a patient’s chief complaint, HPI, past medical history, review of systems and so on. As a result, the EMR does not “tell the story” of the patient’s complaint. And it certainly doesn’t reflect the thinking process of the physician who is evaluating that complaint. The result is that many insurance payors have taken to arbitrary and automatic downcoding of emergency bills containing certain key words, complaints or diagnoses.


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“That leaves a lot of money on the table,” Orcutt said. And that is money that the emergency physician has earned. The key is appealing every possible denial or downcoding. But that takes a lot of personal time by the accounting staff and physicians business managers who understand the chart to reverse these findings. Furthermore, these denials are a double edged sword. If you don’t contest these denials and down coded bills, the assumption on the part of the payor is that you meant to up code the bill. You will soon find yourself on a hit list of suspect groups. And, after a time, this could trigger a very expensive audit of your entire billing operation.

If there is an up-side to all these denials, it is that the consistently aggressive billing companies that contest these denials soon learn the key words and phrases that the payor use to identify those bills that appear up-coded. The inexplicable irony, Orcutt noted, is that these words, phrases and diagnoses seem somewhat arbitrary and capricious. Once these offending words are identified and avoided, the rate of denial starts to decrease. Some billing companies don’t want the low margin return for all the effort spent on these denials so they just push the boundaries of up coding and hope to make up for losses. That strategy of course, can be self-defeating.

Orcutt frequently speaks to packed rooms of clients and potential clients about how to “tell the story” of the patient’s complaint and how the emergency physician works through a difficult thought process to diagnose and manage the patient. And he has them on the edge of their seats thanks to that gravelly voice of an old sage with a bona fide southern drawl.


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“I treat ‘em all like family,” he said. “I tell ‘em the good and the bad.”  There are attending and residents alike. And the emphasis is on teaching them how to tell their story.

“You are telling a non-physician coder why the patient came to the ER, the medical necessity in 60 words or less. And then you have to tell them why what you did was medically necessary. I can give them a ‘cheat sheet’…of key words to use that will decrease their denial rate.”

The bottom line, and he isn’t afraid to say it, is that it means more money for everyone who learns the lessons he teaches.

Returning to the concept of click boxes in EMRs, Orcutt emphasizes that when a record is nothing but template phrases repeated time and again, mistakes can be made that simply cannot be contested.


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“I saw a chart recently where the patient was in atrial fibrillation with a rapid ventricular rate according to the note [and that required a lot of bedside time and effort to control],” Orcutt said. “But the emergency physician had reflexively clicked ‘Normal sinus rhythm’ in the EKG reading box.”  The chart was down coded by the payor and there was little that they could do about it.

Most payors have algorithms that look for acceptable digital formatting of diagnosis codes, but the physician’s EMR does not have the capability of knowing what is in the payors’ acceptable “black box.”

For example, with the diagnoses of “chest pain” and “stroke,” most payors will not pay the physician or downcode these reimbursements greatly for “chest pain” and “stroke.”  It is paramount the physician understands this and applies the acceptable adjectives called modifiers in coding speak to be eligible for payment. PhyCon stresses to its students/physicians that it’s important to place adjective modifiers to ensure they get properly reimbursed.

“I’d like to see us get away from predetermined templates and get back to dictated charts,” Orcutt said.

That approach makes it more likely to be scored by a real person. Even if they are not skilled caregivers, they are more likely to understand the complexity of the case if it is told as a story. “The voice recognition software that is currently available is amazing,” he says with earnest passion.

Oftentimes description of the medical complexity is missing because the boxes don’t supply the right adjectives to describe the patient and how their condition changed over time. This means that the medical decision making, the process that carries the most risk, is the most time consuming and difficult process of the diagnostic workup is often completely overlooked or understated by the “click-box” approach to medical record keeping.

As medical care inevitably shifts from fee for service to value based reimbursement, hospitals and payors are going to pay closer attention to the thought processes of an emergency physician’s diagnostic workup. Those that submit bills for services that truly reflect the complexity of what we do will continue to be rewarded appropriately. But those who push out cookie-cutter bills from EMRs that are mechanically driven will see a slow but steady strangulation of their value and compensation. In  Orcutt’s down home way of saying it, “It’s that simple.”

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