specificity. As a result, they fail to capture
diagnostic data—and the data they do report
fail to reflect the complexity of their patients.
For instance, a physician may document a
patient as “diabetic without complications”
when in fact the patient also suffers from kidney
disease. This will incorrectly force the patient
into a low-risk category, resulting in lowered
2 Poor EHR Template Design. Most providers have been trained to use an electronic
health record (EHR). However, many have not
received sufficient education on setting up EHR
templates correctly and using them to document
encounters accurately and comprehensively.
In one common scenario, physicians customize
their EHR templates in such a way that the templates limit accurate documentation. We worked
with one physician who customized a template
to document up to four chronic conditions. As a
result, it was impossible to fully document any
patient with five or more chronic diseases.
3 Poor EHR setup. When the government introduced the Medicare EHR Incentive
Program, many practices quickly took advantage
of available dollars to purchase EHR software.
In many cases, however, their implementation
efforts were flawed.
Typically, practice leadership focused on capturing financial data but did not give adequate
thought to the long-term capture of discrete
clinical data. For example, many practices have
not configured their EHR to capture lab data
with Logical Observation Identifiers Names and
Codes (LOINC). As a result, the system lacks a
powerful mechanism for identifying and documenting patient conditions.
4 Reluctance to document certain diagno- ses. Physicians sometimes hesitate to
document diagnoses for nonclinical reasons.
For example, a physician may fail to document
“morbid obesity” because he or she does not
want to stigmatize the patient—or initiate an
Alternatively, physicians may be reluctant to
document conditions that will become a permanent part of the patient’s medical record.
Under the Affordable Care Act, pre-existing
conditions are not a concern. But, due to uncer-
tainty surrounding healthcare reform, some
worry that documenting a condition like high
cholesterol today could lead to a loss of cover-
age in the future.
5 Failure to recapture ongoing diagnoses. Many risk-based payment models are
prospective. For example, under Medicare
Advantage, diagnostic data reported in one year
are used to establish the patient’s risk score for
the following year. In addition, as noted above,
diagnostic data do not carry over from year to
year. On January 1, every patient is considered
100% healthy until proved otherwise through
Unfortunately, many physicians are not aware
that their risk-based patients are considered
“healthy until proven sick.” As a result, they fail
to recapture diagnoses by documenting ongoing
chronic conditions annually and reporting them
on claims. In addition, significant medical history—for example, a mastectomy performed five
years ago—may be “lost” if it is not re-reported
All these scenarios produce an artificially low
patient risk score, leading to lowered reimbursements. The solution is to improve documentation
of patient data, especially patient diagnoses.
A careful review of recent claims will uncover
potential instances of under-documentation and
under-coding. This will typically allow a practice
to recoup additional payments.
For example, Medicare Advantage allows
providers a 12-month period to review coding
accuracy and submit corrected claims. For a
practice with $4 million in annual claims, a
review will typically uncover $250,000 to $1 million in additional payments. Just as important,
by improving documentation and data management, physicians can ensure accurate patient
risk scores and payments going forward.
Medical practices that implement effective
documentation processes and optimize their use
of technology will significantly improve their performance under risk-based payment. In addition,
capturing diagnoses accurately and fully will
help leverage data to improve patient care.
Gene Rondenet is the president of qrc Analytics.
Lucy Zielinski is the managing partner of Lumina
use of technology