By: Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC

As much of a team as a physician and coder should be, it is rare to get them to sit down together in a room and talk over the issues of the day. The physicians are in the office, in the hospital, and in the operating room amongst other locations and the coder is busy coding all of the services the physician provides.

One day, I saw a surgeon in the hall and asked if we could just sit and talk. He welcomed me into his office and asked what was on my mind. I explained that there wasn't anything specific, but just that I wanted to talk as we never have time for such an event. He had a few moments and we started to talk about how our lives connect and how better we could communicate with one another.

He understood how busy my day was trying to track him or his colleagues down for answers to documentation questions I had. He thought the first step in better communication would be to have face-to-face, one-on-one meetings on a regular basis. Although he knew he would welcome these meetings, he knows his colleagues might show some resistance, but, "stay on themthey really do appreciate the time you take with all of us," he offered. "Once we have one or two of these meetings, they will see the value of them and will try to be on time for them going forward." This would definitely work for the coders of the department.

We also talked about how valuable shadowing can be. He said he always appreciated having someone right there to ask questions of and point him in the right direction regarding the documentation requirements. Patient care is his focus (as it should be), but he understands the importance of appropriate and timely documentation. But, it has to become a routine. Having a coder on the floor to help facilitate this would be ideal. "I know the budget constraints might prohibit this, but if a coder could be on the floor for even just a few months, the benefits of appropriate documentation and timely billing will far outweigh the cost," he suggested. In many facilities around the country, the focus has been for the physicians to select the level of service as they are ultimately responsible for the claim. However, if they could be educated in real time, the process would become more of a routine and they would be better armed to document and bill more consistently and accurately. Of course, the internal audit process would be in place to confirm this and possibly reeducate as needed. The coders would benefit from this as well. They would have the physicians right there to ask clinical questions or to ask for note clarification. "I don't see how this could be anything but successful," he went on to say.

The other piece of the process that he talked about was the role that the residents play in patient care, documentation, and continuity of care. The residents are the ones who know the whole picture. They are usually the ones to see the patient first-first thing in the morning, upon admission, or just after surgery. They've talked to the residents of other services, they've confirmed with the floor staff when tests are completed and results are records, and they convey this information to the attending physicians as often as possible. Usually the attending will round with the residents once or twice a day. It is then that they have extended conversations with the residents to be brought up to speed on the patient's care since last being seen. The residents' notes often paint the fuller picture. The attending will review the note, ask more questions of the resident, and then see the patient. The doctor I interviewed said that that is when he does his own assessment of the patient along with an examination. He will formulate a plan of care based on his own observations as well as what the resident conveyed to him.

He'll then execute his own note and/or attestation to the resident's information. If the residents could be educated like the attendings are, the combined notes will be more efficient as they will not only convey appropriate care and history of the patient, but they will be in-line with all of the documentation requirements. "Can I make that suggestion too?" he asked. I told him that, in fact, I have often met with residents and fellows to go over these very things. I developed a program on one service where I met with residents twice a year. By the time they were through their program, they may have seen me 10-14 times. By the fifth or sixth time, they knew most of my jokes, could tell me about family history and the other components of the note, and they also knew several very important documentation points that they had made routine. Toward the end of their residency, they would start asking a lot of questions preparing themselves to be attendings. This is where I would take great pride in what I was able to accomplish. I saw how they embraced the requirements and adapted them to their daily work. "I would be happy to see if this could be adopted in other services as well," I told the surgeon.

"Thank you so much for stopping me in the hallway," he conveyed. "I really appreciated you listening to me."

"I should be thanking you," I said. "I look forward to our one-on-one meetings and I am certainly going to see what I can do about your other suggestions. As always, if you have any questions please call me and let's talk again."

"And call me with any questions. If you don't understand what I write, come to the source-I'll be happy to help. We're a team, after all," he ended and left for morning rounds.

Suzan Berman (Hauptman), MPM, CPC, CEMC is currently the manager of Physician Compliance Auditing for Allegheny Health Network (West Penn Allegheny Health Systems).