The Centers for Medicare & Medicaid Services announced several measures guiding the care of patients during the current COVID-19 pandemic. Another important action that will immensely help the health care workers at the forefront is to reduce the documentation requirements for all patients. Health care workers should be unshackled from endless documentation, freeing up their time and resources to take care of the increasing number of patients. CMS, insurance carriers, and other regulatory agencies demand a slew of documentation for billing. This results in health care workers spending more time in front of a computer rather than with the patient. Most of these documents are duplicative or add little value to the care of patients, like pertinent negatives. A moratorium on the current billing documentation requirements should last till we are able to control the COVID-19 pandemic. Physicians and nurses should be permitted to document the necessary minimum for billing purposes and regulatory compliance.
An example of the proposed initial hospital history and physical note (level 3 visit) of a typical COVID-19 patient:
A 68-year-old man with a past medical history of COPD and CHF was admitted with cough, shortness of breath and bilateral interstitial pneumonia. COVID -19 test is positive. Patient is being treated with antibiotics, bronchodilators and experimental antiviral medication. He is saturating 92 percent on 4 liters of oxygen.
On examination, vitals are stable. Lungs bilateral rhonchi.
CXR interstitial pneumonia, CBC leukopenia and thrombocytopenia.
Assessment and plan: Acute COVID-19 interstitial pneumonia, continue medications, monitor lytes, guarded prognosis. Risk of death or adverse consequences high.
The complexity of medical decision making could be captured from a few sentences in the assessment and plan section. A follow-up note (level 3 visit) might look like this:
This 68-year-old man admitted with acute COVID-19 and interstitial pneumonia is on bronchodilators, antibiotics and antivirals. Shortness of breath increased today. Oxygen saturation stable.
Examination: stable vitals, persistent rhonchi.
CXR showed slight worsening. Sodium 120.
Plan: Acute COIVD-19 with interstitial pneumonia. Continue current medications and monitoring. No indication of ARDS. Hold off IV steroids. Check for SIADH. Risk of death or adverse consequences remains high.
Nursing documentation can also be simplified along these lines. Currently, nurses document the same data every so often, amounting to cutting and pasting. They should be able to document meaningful information less frequently in the EMR.
Simplifying the documentation will help physicians, such as intensivists, to focus on the care of patients. This will be important in case of an intensivist/physician shortage, which is happening in Italy right now.
Hospital billing criteria should also be relaxed during this crisis to ease the pressure on physicians to document extensively. Instead of forcing the hospitals to comb for every minute detail in the chart in an attempt to add several co-morbidities to obtain the correct level of reimbursement, payments could be based on the average DRG payment the institution received for a particular diagnosis during previous years.
Caregivers should be able to share physical examination findings unless there is an acute change in the patient’s condition. A single examination policy will avoid unnecessary close contact with the patient by several providers and also will save on personal protective equipment (PPE). Other initiatives, such as reducing the frequency of checking vitals and finger stick blood sugars and corrective insulin administration, will reduce documentation volume.
These measures should also be applicable to the outpatient setting, where resources can be stretched thin. As always, CMS and other agencies should conduct periodic audits to detect any irregularities or systematic fraud.
These actions will go a long way in helping our health care workers during the current COVID-19 pandemic. We need them to take care of the sickest patients and not to produce voluminous notes.
P. Dileep Kumar is a board-certified practicing hospitalist specializing in internal medicine. Dr. Kumar is actively engaged with professional associations such as the American College of Physicians, Michigan State Medical Society, and the American Medical Association. He has held a variety of leadership roles and has authored more than 100 publications in various medical journals and a book on rabies (Biography of Disease Series). Additionally, he has presented more than 50 papers at various national and international medical conferences. Several of his papers are widely cited in the literature and referenced in various textbooks.
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