The transitional care management initial communication requirement stipulates that to report TCM services (CPT® 99495 and 99496), “An interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary’s discharge to the community setting. The contact may be via telephone, email, or face-to-face.” Source: Medicare Learning Network, “Transitional […]
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A) The medical record should be complete and legible
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Tag Archives: Communication
Managed care admissions: Bridging the communication gap between admissions and the business office
AORN guidelines on unintended retention of a foreign body focuses on counting and communication
Patients continue to be stitched closed with surgical sponges, gloves, needles, electrodes, scalpels, wires, tweezers, forceps, scopes, masks, tubes, and scissors left inside them. To combat the problem, the Association of periOperative Registered Nurses (AORN) released updates to its Guideline for Prevention of Retained Surgical Items back in 2016.
How to Prevent Communication Breakdowns in Medical Settings
The statistics are unsettling. According to the Joint Commission of Accreditation of Healthcare Organizations, 65% of hospital deaths and injuries are directly related to communication breakdowns. Nearly 55% of medication errors are caused by faulty communication. These are preventable, treatable problems that would not have occurred if the communication had been clear.
We all know that more paperwork is not the answer. But how can we prevent the needless deaths? What can be done to reduce errors and improve patient outcomes?
One area that must be addressed is that of foreign-born doctors’ accented English. Even those who are proficient in English often still speak with such a thick accent that it is difficult for nurses and patients to understand what they are saying. Unfortunately, it is difficult for them to see the problem because, often, they’ve been speaking English since they were a child and it was good enough to get them through medical school.
But here’s the reality. It’s not an issue of a deficit in their expertise or knowledge and it’s not an issue of their needing “speech therapy”; it’s simply a matter of needing some extra training to improve communication skills.
For example, let’s suppose that a doctor treating a patient turns to his nurse and asks her to administer fifteen milligrams of a medication. She misunderstands him and proceeds to give the patient fifty milligrams of the medication. Now, the doctor knew exactly what he was doing, and the nurse followed instructions as precisely as she could. The problem occurred because of one simple mispronunciation – and could have had disastrous results.
The solution? Providing onsite or online accent reduction training for foreign-born medical professionals. With programs tailored specifically to the medical community, accent reduction specialists can provide the pronunciation training that healthcare workers need while adapting to their hectic schedule.
Depending on the needs of a particular hospital or private practice, training can often be provided individually, in small groups, or even in a large group seminar. With virtual training now available via Skype, classes can literally be scheduled anytime and anywhere in the world, as long as there is internet available.
Please don’t expect your staff speech pathologists to provide this service. They have enough on their plates, and asking them to “treat” the doctors would reinforce the stigma that something is wrong and requires therapy. Instead, locate a speech pathologist off site whose specialty is accent reduction training. That way, this person is brought in as an expert trainer offering continuing education opportunities.
Communication breakdowns are one of the biggest causes of error in medical settings – and many of them are preventable. Accent reduction training is one effective way to reduce the number of communication -related mistakes. What are you doing to improve the communication skills of the foreign-born healthcare workers in your practice?
To find out more about Medically Speaking classes, accent reduction classes for the medical community, please visit http://www.losemyaccent.com. You can also get a FREE online accent screening with personalized tips for practice.
Lisa Scott is a nationally certified speech pathologist who specializes in accent reduction training. Frustrated with your accent or with trying to understand your co-workers? Lisa is passionate about helping you increase your confidence by removing communication barriers. If you are tired of being misunderstood and are ready for a change, please visit http://www.losemyaccent.com.
Communication breakdown: Sentinel Event Alert calls out bad patient handoffs
In September, The Joint Commission published Sentinel Event Alert 58, warning healthcare organizations about the dangers of inadequate handoff communications.
Coder Communication wit Provider
How are you currently communicating with your providers regarding their coding? i.e., a list of patients, CPT codes, ICD10, etc. with corrections?
Currently we have encrypted email system, however we are being told it is unacceptable to send PHI using this source.
Currently we have encrypted email system, however we are being told it is unacceptable to send PHI using this source.
Communication skills to fuel success throughout the facility
Communication – The bridge between providers and coders
This originally published in March of 2014… yet still has some GREAT information for all to use
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Communication – The bridge between providers and coders
March 11, 2014 (Revised and Updated 07 20 2017)
We have all heard the adage “if it wasn’t documented, it wasn’t done”. However, in the role of the medical provider, the fast pace of the job can get in the way of the accuracy of documentation. Unfortunately, in our current healthcare state, our practices have to be fiscally solvent. This is accomplished by accurate coding/billing, AND providing good patient care. Clinical Documentation is a fundamental piece of our total job function coupled with the challenge of providing good communication to our coders for accurate coding a billing.
The importance of good clinical documentation cannot be underestimated. Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care. Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream. If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster. Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.
Documentation will always be a “necessary evil” in the role of healthcare and reimbursement. The conversion to ICD-10 cm (Took place on 10.01.2015) will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system. Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.
Communication is the bridge between the provider of care, and the coder/biller. According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or is an especially skillful writer. As a providers and coders, think about this….. both fall into this category of expertise! The primary function of a coder is to apply that which is written by the provider, into a numeric format; such as ICD-9cm (ICD-10cm). However, once ICD-10cm is implemented, coders will need an excellent understanding of not only medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the written diagnoses per the documentation into the new alpha-numeric ICD-10cm format.
ICD-10 includes many new terms, and certain codes will now require documentation to be more precise and complete to give coders the best “picture” of the care received by the patient via a numeric format. Our challenge as good providers is to document and communicate this new criteria more effectively so we can all share the same understanding of the words needed to continue being fiscally solvent, but to also document the clinical course of care provided.
Unfortunately, most physician and clinical providers don’t have the “inside track” as to what criteria or “words” are needed to clearly document in ICD-9, much less for ICD-10. Both the coder and the providers are challenged even more by the specificity needed in ICD-10. A coder and the clinical documentation specialist are going to be looked up to as the expert. The ‘experts’ will now be looked to help educate and inform providers how to document more clearly and to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions. If we succeed in this endeavor, everyone benefits.
The coding query process can help. The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm training for the coder, clinical staff, physicians and mid-level providers will be a critical point for ICD-10cm and pcs coding success. Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.
As the transition to ICD-10 marches forward, the documentation and support for ‘medical necessity’ remains. The clinical documentation is always the first thing requested for a payment audit or review. Not only as providers are we having to make the leap to ICD-10, but the healthcare payers are also challenged to be proficient at this new documentation system also. We have substantial challenges for payment at this point in time. Concern is are the payers going to be ready also, and how will they respond, if there is a question regarding documentation, payment for your services.
Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.
Documentation for each encounter should include:
§Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;
§Assessment, clinical impression or diagnosis
§Plan of care
§Time spent (eg face to face/counseling-coordination of care)
o Documented time in
o Documented time out
o Documented total time spent (eg at bedside, on monitor(s), etc)
§Date and Signature
§The rationale for ordering diagnostic and other ancillary services
§Past and present diagnoses (If pertinent to the encounter)
§Appropriate health risk factors should be identified (if pertinent to the encounter)
§Patient’s progress, response to and changes in treatment and/or revision of diagnosis
B) Avoid Ambiguous Language
Eg.. “Non-contributory” : The term “non-contributory” is good example of ambiguous documentation. In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed… while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported. Be clear, concise and relevant by avoiding using the term “non-contributory”.
Another term that can be misconstrued is “abnormal” be sure to clarify, qualify, or quantify what is “abnormal”.
C) Clarify your diagnosis
“For a presenting problem with an established diagnosis the documentation should reflect whether the problem is:
a) improved, well controlled, resolving or resolved;
b) inadequately controlled, worsening, or failing to respond/or change as expected
“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)
“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)
c) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)
D) Ordering of Tests and Procedures
Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures
§document ‘what’ test/procedure is being ordered. (i.e. Fetal NST, fetal fibronectin)
§document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)
E) Omitted Information
In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however, should be used infrequently.
Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:
•Create a new entry for the additional information
•Do not annotate in the margins to add information
•Keep all entries chronological and in record sequence
•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”
•Use the actual date of the addendum, amendment or late entry
•Reference the original entry or document by indicating the date of the service
•Always sign the additional entry or document
The need for good communication and documentation brings us back to the term “wordsmith”. Again, both the coder and the physician/provider will need to add this to their job proficiencies. Getting the conversation started is the first step. A quick way to begin is to conduct a mini review of the current physician/provider documentation. The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice. If the coders’ are currently struggling with appending these “difficult” diagnoses now utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes which will be mandatory in October of 2014. Have the coder document and analyze what they’ve found. This quick analysis will help define where better communication and documentation is needed for both the coder and provider.
Here’s a quick process to help enhance communication processes for both the coder and the physician/provider of care.
- Ask the coder(s) and provider(s) for the top 5 mis-coded or difficult to code diagnoses
- Pull the operative/procedure notes that were associated with these diagnoses
- Cross-code the documentation with both ICD-9 and ICD-10 codes
- Identify areas that need to be clarified for the coder with the physician or provider
- Schedule a meeting (face to face) with the coder and the provider and include
- The actual provider notes
- The ICD-9 codes (using the code -book)
- The ICD-10 codes (using the code-book)
Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.
Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
Accountable care units can help streamline communication and reduce length of stay
Accountable care units can help streamline communication and reduce length of stay
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify the potential advantages and challenges involved with establishing a hospitalist accountable care unit
Opening the lines of communication between clinicians and specialists to make care more efficient can be a sizable challenge.
At many facilities, hospitalists shuttle from floor to floor to see patients, each time trying to track down the nurse and other professionals working on each case. Information is typically transferred through an inefficient system of pages and phone calls?sometimes taking hours at a time to deliver crucial pieces of information.
Enter the accountable care unit?a new way of configuring care systems that can help to uncoil tangled communication wires between clinicians and support staff to provide care that is more efficient and streamlined.
In this model, hospitalists work with patients in a specified geographical area of the hospital in conjunction with interdisciplinary teams.
Having patients in one area helps make care more efficient, and as one hospital system in New Mexico learned, can also reduce length of stay and increase cost-efficiency.
A push toward regionalization
Regionalization of hospitalist patients is becoming more common today, because of the benefits it’s been shown to bring, says Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. Those benefits include:
- Improved teamwork, care coordination, and communication
- Fewer readmissions
- Improved resource management to lower cost of care
- Improvements in patient satisfaction
- Reduction in inefficiencies
"I’m pushing accountable care units at all my hospital clients," says Daniels. But while the will is there in many cases to make the change, it’s not always an easy conversion.
Sometimes these initiatives face pushback from physicians concerned about personnel or scheduling issues.
Other challenges include:
- The lack of diagnostic diversity that results from having set teams on a unit
- The challenge of deciding whether teams should be flexible or static
- Hammering out logistical issues, such as how patients should be triaged and how beds are managed
Despite the challenges these initiatives can face, Presbyterian Medical Group in Albuquerque, New Mexico successfully implemented a unit-based model with multidisciplinary rounds about six years ago, says David J. Yu, MD, MBA, FACP, SFHM, medical director of adult inpatient medicine service for Presbyterian Healthcare Services.
The initiative was prompted by a desire to improve inefficiencies and streamline care. "We basically needed to improve patient flow and communication," says Yu. "But we also realized it was a very large process because it involved almost every department, including case managers, physical therapy, nursing, and ancillary services."
To overcome that daunting multi-departmental challenge, officials enlisted the hospital’s Lean Six Sigma group to help coordinate the project.
Presbyterian sought to trade its outmoded care model for something more efficient; one that would improve communication and eliminate delays related to breakdowns in this area.
The changes began as a unit-based project with multidisciplinary whiteboard rounds, a daily meeting that included the hospitalist, nursing staff, care coordination, physical therapy, and other specialists. They discuss the treatment plan and the goals related to the patient care both for that day and the hospitalization for each patient, he says.
The success of that pilot program led officials to implement the same unit-based model in eight of the medical floors at the hospital.
The payoff for the organization has not only been a huge boost in the efficiency of communication, but reduced length of stay for patients. "We’ve seen significant improvements in the average length of stay. This is not because we’ve reduced therapeutic time, but because we’ve reduced inefficiencies," says Yu. Lag time created by communication gaps has been tightened up, allowing patients to move through the system more quickly and efficiently.
To ensure that these new efficiencies weren’t resulting in quality reductions, Yu says the organization also tracked readmissions, which remained steady, confirming that faster discharges weren’t compromising patient care.
Overcoming obstacles
Presbyterian has managed to overcome many hurdles that can make this model a challenge. Although these changes have been successful, they have not necessarily been quick.
"I think in many cases people are just interested in a quick fix," says Yu. This process has been anything but. More than half a decade in, Yu says the program is still a work in progress and the team is continually looking to make improvements.
The initiative took time because it addressed the underlying structure of the organization and didn’t just make surface changes that can’t be sustained.
"I like to use the analogy of painting a wall. The painting is the easiest part. What takes time is all the prep work getting the surface ready," he says.
Most organizations just want the paint on the wall?they aren’t willing to address work needed to fix the underlying structure. "This really is a foundational project that takes months and years to develop and mature," he says.
This project not only solved many communication problems at the organization, but it also helped to ready the facility for the new era in healthcare ahead?one where revenue is driven by quality, not volume.
Organizations that want to thrive in this new model will need to rethink antiquated processes and systems going forward, he says. Those that don’t may not survive in this model.
Steps to success
For an initiative like this one to be successful, it has to be well designed and have support?both in commitment and in terms of dollars?from upper management.
"A lack of resources is another reason why a lot of these projects fail," says Yu. "The hospital doesn’t want to fund it. If only one department is very excited about the project, it won’t work."
The model involves a major change that requires support from multiple disciplines. "Without the support of leadership it’s not going to succeed," he says.
You also have to give hospital staff members a reason to support it, which may be the biggest challenge.
"It has to successfully answer the question, ‘What’s in it for me?’ " says Yu.
If the changes are onerous and provide little benefit to the people they affect, there’s little incentive for anyone to support it.
"Understand your worker and your project," he says. And overcoming barriers may involve system and even contract changes, he says.
If you can get that support, you can make changes that will improve communication and consequently care at your organization?and help ready it for the changing healthcare landscape of the future.
HHS Warns of Phishing Attempt Disguised as Audit Communication
The U.S. Department of Health and Human Services (HHS) has issued an alert, warning of phishing attempts disguised as audit communication. It has come to our attention that a phishing email is being circulated on mock HHS Departmental letterhead under the signature of OCR’s Director, Jocelyn Samuels. This email appears to be an official government […]
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