The Checkbox Patient
You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.
I get frustrated when I see people try to squeeze an entire person into a series of checkboxes. This has gotten under my skin for a long time. Apparently, Medicare agrees with me. Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.
The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time. I provided the bold text.
The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.
The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.
CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.
Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.
Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.
If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.
So, be wary of programs that do too much for the nurses. If a program doesn’t require at least a short narrative, it likely will not get done. If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.
Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information. You need reports and communication. You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.
You do not need any more denials. I assure you.
I agree wholeheartedly. Over and over I see not enough documentation to substantiate homebound status, medical need or provision of medically necessary services. There’s nothing to support the diagnoses codes or the other Mitems that are case mix.
Lisa, your vast experience in coding and home health consulting gives extra weight to you comment. I think people forget that past coding, payment and denials, the clinicians who follow the nurse must have enough info to take care of the patient. Without it, things much worse than a denial or poorly coded episode result. I know that I could not follow a lot of nurses and adequately care for the patient.
Thanks, again.
Our Point of Care system does use checkboxes, but there is plenty of room for elaboration in a “comment” box and lots of additional “Tabs” that can be opened for required details. It’s just that the system is complicated to navigate and “support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.” Support for this system SUCKS at best and non-existent at worst. A good thing about it is that the nurse who goes out to see the patient on a PRN visit and has never seen the patient before has all the information she needs at her fingertips; unless somebody is lollygagging about and didn’t “Sync” her last visit. The diagnoses, medication list, Goals and Interventions, and Clinical Notes are there even if the last visit isn’t. Nothing is perfect; not paper charting, nor computer software. It seems that in an imperfect world, we are supposed to be. Bummer.
Gail, I have embarrassed myself by taking some pretty big computer vendors to task over their documentation. It seems that all systems invariably allow for individualization of notes. I have my theories about why some programs lend themselves to poor documentation and others don’t. One is that in trying to simplify the nurse’s task of documentation, the programs have made it almost too easy to simply check a box and move on. In all of the systems I have reviewed, I have never seen a check box for ‘I only get short winded when I walk 20 feet after eating and then it only happens if I took my atenolol.” This is important information.
Ease of system use is critical. I think that regardless of the system, agencies should start by giving access only to the parts of the system that are critical to getting the job done. Most software vendors include training in their pricing. My preference would be to teach the nurses how to use only the parts of the program necessary for their job and then later come back for more advanced training. The way that adults learn is different from kids and I think whatever is taught in the first four hours of training is what the trainee will retain unless they are actually using the computer as well.
My favorite program, Healthcare First, (an entirely biased opinion, by the way), is also not perfect but it is getting there. Within the screen, there is the ability to contact support as long as the computer is online. I can’t tell you how many times I have used that button. Sometimes at night when their office is closed, I feel like clicking it to ask for emotional support when writing appeals.
The universal component of any system that makes it a success is to have someone in the agency who is the cheerleader. Two things can ruin an implementation. First, if the leadership staff entertains complaints about the program, it will foster a negative attitude. This does not mean you shouldn’t listen to the staff and take their concerns to your vendor but it does mean that after a concern has been voiced, you need to leave it alone until you receive a response from the vendor. There is no possibility that talking about it will make the answer come sooner. The second and deadliest sin is to allow the field staff to hear any discontent on the part of the leadership team. At that point, it is over and you might as well go shop for another system.
In the book, ‘The Ice Cream Maker‘, which I highly recommend, the author talks about allowing staff to participate in decisions. If you haven’t already purchased a system or if you are trying to narrow down concerns and improve processes, it is a good idea to bring together or survey as many team members as possible. People who have input into a decision are less likely to trash it. Just saying.
J. “trying to simplify the nurse’s task of documentation, the programs have made it almost too easy to simply check a box and move on.” Agree
J. “Ease of system use is critical.” Agree. Should have known we might be in trouble when our first educational session took 2 hours for the instructor just to get the system up and us logged in.
J. “the ability to contact support as long as the computer is online.” Oh, but that can’t happen with our system. The nurses have to call Debbie, tell her the problem, if she can’t “fix” it over the phone, they have to come in, Debbie has to call the Tech support person (good luck with that) and usually wait for a response.
J. “Entire 4th paragraph.” Agree
J. “People who have input into a decision are less likely to trash it.” Agree
We have many sessions with staff for input, and you are right, it helps a lot. Even with all the problems, the staff has persevered and hung in there, and that makes them great. As I said when I walked through the doors into the lobby of the nursing school, “It’s too late to turn back now!”