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91. Is this the end of note bloat? | Breaking down the 2023 documentation guidelines

18 snips

Nov 7, 2022

The podcast discusses the upcoming changes in documentation guidelines for coding, billing, and compliance, highlighting the burdensome nature of the current guidelines. They emphasize the potential for the new guidelines in 2023 to reduce the burden of documentation and allow clinicians to prioritize patient care. The importance of real-time documentation in the emergency department and the value of capturing the ED course are also discussed. The chapter also explores the process of importing radiology reports into a patient's chart and the challenges of reconciling independent interpretations. Additionally, the podcast highlights the importance of documenting the consideration of escalation or de-escalation of care and discusses the disagreement between the American Medical Association and CPT regarding guidelines for critical care time in 2023.

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Introduction

00:00 • 5min

Changes in Documentation Guidelines and the Impact on Clinicians

04:51 • 20min

Streamlining the Job Search Process and External Record Review in Documentation Guidelines

25:19 • 4min

The Importance of Real-time Documentation in the ED

29:10 • 23min

Importing radiology reports and reconciling independent interpretations

52:15 • 3min

Documenting Escalation or De-escalation of Care

54:52 • 10min

Disagreement on Critical Care Time and Guidelines for 2023

01:04:25 • 2min

28 years ago, the die was cast for how emergency department encounters were documented. Since then, we've had note bloat, click fatigue, and too much attention placed on things that really didn’t matter. All of that is slated to change in 2023 with dramatic new documentation guidelines (that today’s guest calls ‘refreshing’) are implemented. When was the last time you heard the word ‘refreshing’ used when it came to charting? And a massive thank you and hat tip to my friend Matt DeLaney who now runs ERcast - he was the first to alert us to these guidelines and interviewed Jason when they were first announced.

Guest bio: Jason Adler, MD is a clinical assistant professor of emergency medicine at the University of Maryland where he is also the director of compliance and reimbursement. He is also the vice president of acute care solutions at LogixHealth.

Episode Sponsor: Ivy Clinicians. Curious if there’s a better clinical opportunity out there? Ivy is the simplest way for physicians, PAs, and nurse practitioners to match with jobs they love. With Ivy, you can find all 5,549 emergency departments, filter by your preferences, and connect securely with the right employers. All for free.

For full show notes of this episode and all sorts of other goodies, visit our podcast website

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We Discuss:

History and physical documentation are now at your discretion;
Heavy value is placed on cognitive work and medical decision making;
History from a non-patient source is valued in these guidelines;
Ordering a test is equally valued as not ordering a test;
Consideration of escalation or deescalation of care;
In addition to documenting your shared-decision making conversations, your MDM should include;
Population health - Stable means something different when it comes to documentation;
Social determinants of health;
There is a heightened emphasis of independent interpretations of separately billable procedures (EKGs, X-ray, CT, U/S);
Jason’s take home points;
And More.