How to Win Friends and Influence Physicians

Respect is the key that will open the door for them to receive the information that you present.

If you don't know what someone's expectations are of you, then the best thing to do is to ask. 

The chances are good that if you are reading this article, then you work to provide medical coding and billing services for physicians.  The chances are also pretty good that you care about the quality of your work.  In your profession, your all-consuming objective should be to ensure the financial success and good health of the physician practice that you work for.  By "financial success", I mean that you help the practice to legitimately maximize the reimbursements that they are due.  By "good health", I mean that you help it to identify and avoid the industry's legal and regulatory pitfalls.  The quality of your work will greatly depend upon your ability to provide feedback to the physicians and effect positive change.   It is here that you define your worth to the physicians that you serve by helping to keep them in practice.  In the big picture, you help to avert the healthcare crisis that is looming on the horizon.  This article is designed to help you achieve this objective by helping you to help your physicians.

The title of this article speaks volumes: "How to Win Friends and Influence Physicians".  It is adapted from the title of one of the best selling, most influential books of all time, How to Win Friends and Influence People, written by Dale Carnegie.  I used it, not to borrow its principles (which are timelessly applicable), but rather because the phrase perfectly emphasizes the all-important problem that we face as medical billers.  How do we "win over" our physicians and help them in their cause? How do we effectively influence our physicians to change their inadequate or high-risk documentation practices so that they can quickly and safely receive full remuneration for the services that they provide? 

The agenda for this article will follow with me talking about the "Who?", "What?", "When?", "Where?" and "How?" questions of medical billing feedback.  Actually, it will follow the order of "What?", "Who?", "When?", "Where?" and "How?" (Even though the first list sounds better).  Anyways...I will share my perspective with you.  The information comes from my experience as a compliance officer for a medical billing company that provides coding and billing services for emergency physicians.  I trust that you will find that the same principles that work for emergency physicians will also work for the particular specialties that you serve. 

The first question to address is "What?"  So, what is "feedback" exactly and what type of information should you feed back to the physician?  "Feedback" is the transmission of evaluative or corrective information about a process to the original or controlling source.  The "controlling source" in this case, is the physician and the "process" is the physician's documentation of the service that he or she provided.  I always begin feedback sessions with physicians by pointing out that the practice of medicine may be their calling but documentation is their livelihood!  They get paid to document and their documentation is the only acceptable method of substantiating their services to the payer.  Insurance companies demand proof of medical necessity.  The medical record should verify precisely what services were actually provided, the site of those services, the appropriateness of those services, the accuracy of the billing and the identity of the provider.  AND SO, we "transmit evaluative or corrective information" about that documentation back to the physician.  This information should be recorded when you code the physician's documentation or when you audit the physician's coding of his own documentation (if this is applicable to you).  The results should highlight any and all failures to document (or code) a service accurately and completely. 

In order to provide this information, it is recommended that you store this information on every physician in a database (for example, Microsoft Access) so that you can report monthly, quarterly and annually on the trends of documentation insufficiencies.  It is also recommended that you maintain chart copies to show the physician specifically what was lacking in his or her documentation.  The types of data stored should relate to missing or incomplete medical charts, missing signatures, illegible documentation, insufficient documentation of surgical procedures or medical procedures, and most importantly, insufficient documentation of any of the components of an evaluation and management service (which are the history, exam, and medical decision making, or time in some circumstances).  Evaluation and Management (or E/M) services usually constitute more than 80% of the physician's income and are thus considered the physician's "bread and butter".  It is therefore recommended that you focus your energy primarily on E/M services. 

A good example of an E/M trending report that I use often, records the occurrences of possible down codes.  A down code occurs when the level of the history and/or examination fails to meet the same level of medical decision making (or MDM) in an E/M service.  Since an E/M service can only be coded to the lowest level of the three components, the service "down" codes (unless counseling and/or coordination of care dominates more than 50% of the service). 

I am careful to point out that these are referred to as "possible" down codes.  In some cases, the level of history or examination may be legitimately lower than the medical decision making (or MDM).  For example, a patient could present with a traumatic extremity injury.  The physician could order an x-ray, personally interpret the x-ray, administer a controlled substance intravenously and consult with an orthopedic surgeon.  In this scenario, the MDM would be measured by an E/M audit tool as high; however, a comprehensive examination may not be medically indicated and thus, the service would not be a "true" down code.  On the other hand, depending upon the actual cause and/or circumstances surrounding the chief complaint (for example, a motor vehicle accident), a comprehensive examination may be warranted if the potential for another injury exists.  The extent of the history and examination are determined by the clinical judgment of the practitioner.  Only the physician will know if he or she failed to document everything that was performed or that wasn't performed but was medically indicated.  The purpose of the report is not to identify actual down codes but rather to identify possible down codes and to indicate documentation trends back to the physicians.

An entry is made into a database table if the history or examination level fails to meet the MDM level.  The information that is recorded is as follows: the patient's account number, the physician's name, the possible level of E/M service, the actual level of E/M service, the E/M component that was low (i.e., history or exam) and the E/M sub-component that actually caused the down code.  The E/M sub-components for the history are recorded as the history of present illness, the review of systems or the past, family, social histories.  The E/M sub-components recorded for the examination are the organ systems or body areas.  You may also include other areas such as capturing critical care if a critical care service was indicated on the chart but no critical care time was documented. 

Another important note to make concerning the capture of this data is that it should be gathered consistently against a constant, industry standard, coding system.  Feedback about coding is arbitrarily subjective when you consider the subjective nature of defining the CPT E/M nomenclature without an industry standard coding system that the majority of payers recognize, for example, what constitutes a "brief" versus an "extended" history of a present illness or what exactly constitutes a "moderate" versus an "extensive" amount and complexity of data to be reviewed?  Thankfully, we have such an industry standard in the Marshfield Clinic Audit Tool which provides a definite way to measure an E/M service.  The development of this tool was (arguably) initiated by a past Medical Director of Healthcare Financial Administration (or HCFA), which is now the Centers for Medicare and Medicaid (or CMS).  This event roughly coincided with the release of the 1995 Documentation Guidelines.  Although the Regional Carrier Medical Directors at that time declined to accept the tool as official, they used it for auditing and it subsequently became the best standard for accurately measuring an E/M service.  Even so much, that some carriers have now officially adopted it (carriers such as the Pennsylvania Medicare Carrier and the Florida Medicare Carrier).  Also, thanks to the Freedom of Information Act, it is now publicly known to be the tool used by the Office of the Inspector General to audit physician services.  The use of this tool will unquestionably give your feedback weight and authority in the eyes of your physicians whether you are identifying insufficient documentation or improper coding.

To reiterate, the benefit of storing physician down code information in a database is that it provides you a way to trend insufficient documentation and thus pinpoint potential weaknesses of each physician.  Once they are identified, then they can be corrected.  For example, you may see a trend for Dr. Smith indicating that he doesn't understand the need to obtain four separate and distinct elements from the history of the present illness when he evaluates and manages a high severity presenting problem.  You may see that Dr. Roberts comes short on documenting comprehensive examinations because he has a style of documenting body areas instead of organ systems and he is not aware that Guidelines require at least eight organ systems for a comprehensive exam.  The trending analysis may reveal that Dr. Johnson fails to obtain a complete Reviews of Systems across the board.  After pulling some of her charts, you realize that she is using a bad paraphrase of the "all other systems are negative" statement and thus, is thus not getting credit.  You may uncover that still another physician has no EKGs billed.  After closer review you realize that he is not indicating that he personally interpreted the test.  Without a database, you do not have the bird's eye view and thus your analysis will be hit or miss.  With it, you can tweak and fine tune your physician's documentation practices and help them realize the maximum legitimate reimbursement for the services that they provide.

Another critical area of feedback involves alerting the physician to compliance risks.  It is your responsibility to be the expert on billing risk issues for the physician.  For starters, make sure that you are very familiar with the Office of the Inspector General's Compliance Program Guidance for Third-Party Medical Billing Companies.  This provides the blueprint for developing a compliance plan that will keep you and your clients safe.  You need to understand the rules of the game and you must be ever vigilant to guard your physicians against certain practices that could put them at risk for fraud and abuse.  For example, let's say you determine through an E/M distribution report (again data from a database) that Dr. D is reporting 9% critical care when every other physician in the practice is between 2% to 3%.  After you pull some charts, you discover that he is reporting critical care time on ankle sprains and sore throats.  At which point you determine that some education is definitely in short order.  To help him out, you prepare copies of the guidelines for critical care reporting from the CPT manual and from the Medicare Claims Processing Manual and schedule a meeting with the group administrator. 

Take another example of a situation that prompted me to write to one of our Emergency Department Group Administrators.  It email wrote:  "Dear Dr. So-and-soan issue was relayed to me concerning medical record addendums.  To summarize, incomplete charts (actual pink copies) were sent back to you.  Several physicians in your group completed the charts with handwritten, inked notations (on the pink copies) that were neither signed nor dated and then were returned back to our office.  Because of the compliance risk to you of unidentified notations that might not match the official record at the hospital, we just need confirmation from you in writing that each of these notations has a matching addendum that can be accounted for at the hospital's medical records department; otherwise, we wish to make you aware of the risk involved in billing for these encounters."  I closed respectfully and also attached excerpts from both the Florida Administrative CodeBoard of Medicine and from CMS' Conditions of Participation which concerned late entries in medical records.  Needless to say, he was very appreciative and corrected the problem immediately.

We live and breathe and work in the most regulated industry that there is.  Do not think for one moment that your physicians have the time or energy to stay on top of the ever-changing mountain of rules and regulations.  They will need to depend upon you to provide them with alerts and guidance on the myriad of sensitive issues that are out there just waiting to ensnare their practice.  In order to provide this information, make sure that you subscribe to reputable, industry specific newsletters such as the CPT Assistant, Part B News and the Part B Insider.  Periodically review the websites of CMS and the Medicare Carrier in your state, and of other major insurance companies for news that might affect your clients.  Also look to the Specialty Society's website that pertains to your client's practice.  Stay abreast of coding changes from the CPT and ICD-9 manuals by always having the latest versions on hand and by reviewing such publications as the book CPT Changes: An Insider's View.  Make sure to download and review the OIG's Work Plan every year which will tell you specifically the high risk areas that the OIG auditors will be focusing on in that next year.  Be sure to network with trusted industry professionals since they can provide to you valuable insight at critical times.  All of this is a lot of work but it cannot be avoided if you wish to provide your physician with the customer service that they deserve.

In 2006, the CPT introduced new codes for Infusion and Hydration services.  The big question for our company was whether we code bill for the services for our emergency physicians.  I went to a trusted expert in the industry with connections to the CPT Editorial Board, who advised me to wait since a clarification on the issue was pending.  We educated our physicians and refrained from billing.  It turned out that in a recent publication of the CPT Assistant, that CMS determined that there was no practice expense value in the service.  Since our emergency physicians are not employed by the hospital, they have no practice expense and cannot bill.  The article went on to say that billers should check with commercial payers to determine each payer's individual payment policies.  For the billing companies that billed these procedures for emergency physicians, they are now presented with the uncomfortable prospect of having to tell their clients that lump sum refunds may be requested.  In these scenarios, it will only be a matter of time before the insurance companies follow Medicare's lead and request overpayment refund requests.  For large groups that have made a lot of money, it turns out to be fleeting and dangerous.  It is unpleasant when your client has to refund a large lump sum overpayment from a retrospective denial.  You can see through this example where it pays then to be properly connected to trusted information sources.      

Another good example concerns the recent push towards Pay for Performance.  Last year, CMS implemented the Physician Voluntary Reporting Program and encouraged physicians to begin voluntarily reporting on quality performance acts.  Our clients would not have participated without our education efforts and prodding.  This paid off recently because the government passed the "Tax Relief and Heath Care Act of 2006" which eliminated the 5% cut and further directed CMS to develop a quality reporting system for physicians known as the Physician Quality Reporting Initiative.  Beginning in July 2007, physicians who report quality data to CMS will be eligible to receive a 1.5% bonus payment for their services.  I can tell you that because of our company's vigilant efforts, we are prepared now to report and our physicians are prepared to receive additional reimbursement for their services.  Make sure that you stay abreast of changes that can impact your client's bottom line and that you alert them to such things in a timely manner.

Hopefully now you have a better idea of how critical it is for you to provide quality feedback to your physicians.  Not only does it ensure their success but it ensures your success in this industry as well. 

Another important message that I want to communicate to you deals with respect.  AND SO, I want to emphasize the need for you to shower your physicians with respect.  Respect is the key that will open the door for them to receive the information that you present.  The first important note concerns the "Who?" of physician feedback.  It is most important for you to minimize the number of people from your organization who can interact with your client.  It is preferable to limit this to one person.  With too many messengers, you run the risk of sending mixed or contradicting messages that can cause more harm then good.  Filter all contacts through one client liaison if possible.  On the flip side, have your client identify one physician contact as well; usually this will be the group administrator.  Normally it is better, especially when dealing with sensitive issues, for the group administrator to communicate with the other physicians in the group rather than you.  Sometimes the door will be opened for you to address other physicians in the group directly, but (out of respect) let the group administrator facilitate this.

Concerning the questions of "When?" and "Where"...allow respect for the physician's time to dictate your actions.  Begin all of your initiated conversations with kind and courteous questions such as: "Is this a good time for you?" or "Are you free to talk for a brief moment?"  Pay close attention to their answer, especially to their voice language (as opposed to body language).  If he or she answers "no" or if you detect that it's not a good time from the tone of their voice, then do yourself a big favor and quickly end the conversation.  Close by asking the person to contact you at his or her earliest convenience.  A little show of respect such as this will help to ensure that you have the physician's undivided attention the next time you speak with him or her and that will help you to communicate your message effectively.  Also, when they do call, be brief and get to the point of your message.  If you are thoughtless here, then it will not matter how great the information is that you have to give to them; it will fall on deaf ears and an unreceptive mind.  The same principal applies to the question "Where?"  If a face-to-face meeting is required then allow them to determine the place.  Sometimes the locations and settings of your meetings are just awkward and uncomfortable.  Never let your clients see you distressed about these matters.  In my experience, I have sat in many undesirable emergency room "utility closets" all day long, just to meet with the physicians in their few precious free moments between patients.  It was not the most advantageous meeting place in my mind, but it was all they could do.  When they see you sacrifice your time or comfort for their benefit, then you will see them open up and take heed to your message.

Not that we haven't already touched on a few of the principals of "How to Influence Physicians", allow me to discuss in greater detail, how to reach your physicians for just a few moments.  This is where I would encourage you to employ some of the timeless communication techniques taught by Dale Carnegie (or Ken Blanchard or Steven Covey or Zig Ziglar or Tony Jeary), because they all work.  As Mr. Carnegie said, "Don't criticize, condemn or complain, smile, be a good listener, show respect for the other person's opinions, try to see things from the other person's point of view, admit your own mistakes and apologize, and give praise when it is deserved."  All of these principles have worked in the past, they work now and they will continue to work in the future.  But let me touch on a few other important points.

Former Mayor Rudy, and now presidential hopeful made the following statement in a recent leadership conference.  His message was "Prepare, Prepare, Prepare!"  It was preparation that enabled him to lead his city through the terrible circumstances of September 11th.  Make sure that you prepare carefully for each and every meeting with your doctors.  I perform constant documentation in-services for our emergency physicians.  Whenever I go to a meeting, I always spend several days familiarizing myself with the physicians' documentation styles, their charting system, and any particular areas of interest that will pertain to them.  For example, if they practice at a teaching facility then I make sure that I am prepared to answer questions on the Teaching Physician Rules.  If they employ non-physician practitioners, then I make sure I am prepared to discuss any issues that might arise with nurse practitioners or physician assistants.  I make sure that I personally review any down code examples carefully before I go over them with the physicians.  I do this to make sure that I can clearly explain to them the reason why the chart down coded.

In order to effectively communicate the message, I always make it a point to make my expectations clear to the physicians that I meet with.  Usually, this entails me wanting them to change the way they document.  I also try to discover and understand their expectations from me.  If you don't know what someone's expectations are of you, then the best thing to do is to ask.  Usually they will tell you.  Through this process, you must try to invent some opportunities for mutual gain. 

A good example of this is seen in the way that the documentation seminar (that I often present) has evolved since I first began presenting it.  I would typically meet with my docs and conduct an hour-and-a-half PowerPoint presentation.  My expectation has always been to invoke changes in the way they document.  Over time, I learned that it is the common expectation of the emergency physician to receive a quick, simple and easy solution to their problem.  For a long time, I failed to effectively reach our clients because I failed to negotiate with them.  I failed to create solutions that would take into consideration my personal expectations as well as theirs.  I tried to teach them all of the subtle nuances of CPT coding while I tried to forcefeed them the documentation guidelines line by line.  Needless to say, an emergency physician has a short attention span and I usually lost my audience.  When I finally wised up and paid attention to what their expectations were, I then realized that I needed to change my approach.  I also learned that if you know each other's expectations and seek to create options that will benefit both, then what you will do is empower the other person to change. 

Here was the solution.  Simplify the message!  I took another look at the down coding issue and realized that my physicians' down coding problems only related to high severity nature of presenting problems.  The 99285 and the 99284 both shared a high severity nature of a presenting problem.  I then simplified the message by telling them that if they identified a high severity presenting problem that then they should remember the catch phrase "High 4-10-2-8".  To invoke a small sense of obligation, I gave them a small gift, a clicker pen that displayed the little message in a little window as they clicked it.  As they clicked through, it read...High Severity [CLICK] High-4-10-2-8 [CLICK] 4 HPI [CLICK] 10 ROS [CLICK] 2 PFSH -and- [CLICK] 8 OS.  I then looked for what would be considered some "no-brainer" high severity problem indicators.  After consulting with several physicians and searching my own knowledge base, I determined that if the physician ordered multiple ancillary studies (such as lab work, an x-ray and an EKG in conjunction), OR if any special study was ordered such as a CT Scan, Ultrasound or MRI, OR if IV medications were administered, OR if multiple intramuscular injections were given, OR if the patient was admitted or transferred then it was a pretty good indication that the patient was presenting with a high severity problem.  I stopped trying to explain the CPT nomenclature which, for some reason, always seemed to get lost in translation.  For example, the definitions for the Nature of Presenting Problem levels from the CPT ... "A high severity problem is a problem where the risk of morbidity without treatment is high to extreme; and/or there is a moderate to high risk of mortality without treatment..."  Now this is way too subjective for consistent application.  The answer to my problem and the physicians' problem was in the acronym "KISS"keep it simple stupid!  So, I told the doctors ... Five indicators and then bam!  4-10-2-8!  Don't let the chart leave your hand until you make sure you have all your elements! 

And that's it!  I let the physicians loose with some simple guidelines and empowered them to discover the ways to fix their own down coding problems.  They are extremely intelligent people.  They truly know what to document better than I do.  They just needed a guardrail to keep them from driving off the reimbursement bridge.  High 4-10-2-8 provided just thata simple, short, easy-to-remember solution!  And it worked.  Documentation now improves significantly after each and every seminar and I get thanked profusely the docs (especially the ones who get bonuses for good documentation).

In closing, I think you know that I'm no Dale Carnegie so I will leave the finer points of teaching human relation skills to the professionals but basically it is wrapped up into respect.  (Even to the point of respecting those who aren't respectful themselves.  You will usually come out on top in these matters if your patient.)   If you want to be successful in your business then help others to be successful and help your physicians help themselves.     

Kenneth Engel is the Vice President, Corporate Compliance Officer, and a founding associate of Martin Gottlieb and Associates, a company that provides coding and billing services for emergency physicians who cover 48 emergency departments from six states.  He is also the founder and a past president of the Jacksonville South Chapter of the AAPC in Florida.