Use of a Template to Improve Documentation and Coding

516 July-August 2001 Family Medicine Use of a Template to Improve Documentation and Coding Edward A. Rose, MD, MSA; Arti M. Deshikachar, MD; Kendra L. Schwartz, MD, MSPH; Richard K. Severson, PhD Background and Objectives: Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions. Methods: Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note. Results: Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors. Conclusions: The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes. (Fam Med 2001;33(7):516-21.) Accurate assignment of the evaluation and management (E&M) code for an office visit is challenging. 1 The E&M coding rules designed by the Health Care Financing Administration (HCFA) have been described as unnecessarily complex and are currently in the process of redesign, in part because of the number of complaints about them. 2 This complexity had led to the publication of coding aids such as the Pocket Guide to the Documentation Guidelines published by the American Academy of Family Physicians (AAFP). 3 Many large practices have tried to resolve the entire coding and compliance issue by hiring professional coders, thereby taking the decision away from clinicians. The use of progress note templates that can aid in accurate coding may help return E&M coding decisions to clinicians while reducing improper coding. Although templates can improve the informational content and legibility of a note, it is not known if they can also help improve the accuracy of coding and billing. To evaluate the effect of a template on coding, we designed a template for a common office problem, the diagnosis From the Department of Family Medicine, Wayne State University. and treatment of group A beta-hemolytic streptococcus (GABHS) pharyngitis. We hypothesized that our template would increase thoroughness of documentation and increase the accuracy of coding, compared with that achieved with standard progress note charting. This report presents the results of our implementation and analysis of this new tool in a family practice residency office setting. Methods Settings The study practice site was the suburban Detroit family practice residency clinic of Wayne State University. Seven attending physicians and 12 resident physicians practice at the site. Our internal patient encounter database revealed that the average patient volume is 1,200 patients per month, and the average age of patients is 39.6 years. The progress notes routinely used at that site were designed to facilitate recording of a full review of systems, past medical-family-social history, and physical examination. 4 The progress notes include check boxes for all three of these contact areas, which can be marked as normal or can refer the reader to the handwritten note if further explanation is needed.

Special Series: Practice Management in the Residency Setting Vol. 33, No. 7 517 Instrument We designed a progress note template to use with patients who have signs and symptoms of GABHS pharyngitis. The template was based on published algorithms that classify the relative probability of a GABHS diagnosis into three levels: low, moderate, and high. 5-7 The indicators included on our template were fever, absence of cough, cervical adenopathy, and severe pharyngeal erythema. The template also prompted the clinician to add up items recorded in each section of the note, assisted in the assessment of complexity of medical decision making, and then brought these factors together to arrive at an appropriate E&M code. The template is shown in Figure 1. Procedures The template was used with 50 patients who presented with a complaint of sore throat between July 1 and October 31, 1999. The study procedure was as follows. The medical assistant who performed the intake assessment identified patients with a sore throat complaint, placed the template on the chart, and recorded that patient s name and the date on a log sheet. No other progress note form was placed on the chart. If the physician concluded that the visit was more complex than a sore throat (for example, the patient had a comorbid condition that required additional documentation), the template was removed by the medical assistant and replaced with a standard progress note form, and these visits were excluded from study. Since the template may have had an educational effect on physician behavior, we selected a comparison group from visits that predated the template study period. The comparison group was comprised of visits of patients with a diagnosis of pharyngitis who were seen in the 6-month period just prior to the intervention. The comparison group consisted of 50 patients who were selected from the list of 121 eligible patients by pulling the chart of every other patient on the list up to a total of 50. These 50 records were examined in a similar fashion. To ensure blinding of the 50 pre-intervention and 50 post-intervention records so that our reviewers would not know the visit was coded, we used the following procedure. A list of 100 random numbers between 1 and 1,000 was generated, and progress notes and templates were assigned a code number. The code number was then written on the study copy of the progress note or template, along with the age and gender of the patient, whether the patient was new to the practice or established, and the level of service charged. Specifically excluded were the patient name, the date of service, and the name of the physician who saw the patient. A medical assistant maintained a log sheet matching patient names and visit information to the assigned code number. One of the authors then extracted information from each of the 100 progress notes and templates onto a blank template. Another author reviewed the notes and extracts, and differences between the two reviewers were resolved by consensus. The code number was entered in place of the patient s name, along with whether the patient was new or established as well as the gender and date of birth. The extracts were arranged in numerical order for review. Each coded extract was then analyzed, as designed below. Data Analysis The following variables were entered into a database: patient age and gender; the number of elements listed for history of present illness, review of systems, past medical, family, and social history, and for physical examination; the diagnosis, including the likelihood of GABHS; whether a rapid strep screen was indicated; whether or not a strep screen was performed; the results of the strep screen; whether antibiotics were indicated; whether antibiotics were given; name of antibiotic given; and whether or not a first-line antibiotic was used. Finally, the note was assigned a level of service based on completeness of the note and complexity of the case according to coding guidelines published by the AAFP. 3 After all variables were entered into a database, the code was broken to allow identification of patient visits recorded on templates versus progress notes and the level of service charged. Differences between the template and progress notes groups in the means of continuous value variables (such as the number of physical exam items) were assessed by an unpaired t test assuming unequal variances. 8 Differences between the template and progress notes groups in the proportions of categorical variables (such as whether or not a rapid strep test was done) were assessed by a test for a difference in proportions. 8 Decision-making results were compared using chi-square analysis. Results Of the original 100 chart notes, 96 were included in the analysis. Four of the original (pre-intervention) progress notes were illegible, while all of the templates were legible, resulting in 46 progress notes and 50 templates for inclusion in the database. The average age of all patients in the study was 31.0 (SD=4.6) years. Twenty-nine (58.0%) of the template patients were female, compared with 28 (60.8%) of the progress note patients. Template patients tended to be somewhat older than progress note patients (average age 32.8 versus 27.6, respectively; P<.05). Documentation Documentation of history and physical findings is shown in Table 1. Given the differences in age groups

518 July-August 2001 Family Medicine Figure 1 The Study Template

Special Series: Practice Management in the Residency Setting Vol. 33, No. 7 519 between the template patients and the progress note patients, we stratified by age in our evaluation of thoroughness of documentation. Analysis of the pooled data revealed that, compared to progress notes, templates had more history of present illness items (5.3 versus 4.3; P<.001), more past medical-family-social history items (1.8 versus 1.4; P=.012), and more physical exam items (10.5 versus 6.9; P<.001). There were more review-ofsystems items recorded on the progress notes (4.1 versus 1.1; P<.001) than on the templates. All of these differences between templates and progress notes remained statistically significant when restricted to those patients less than age 30. However, when considering those patients age 30 and older, only the review-of-systems items and the physical examination items were significantly different (P<.05). Diagnosis and Treatment If a patient was assessed as having a high probability for GABHS, the clinician would not be expected to run a rapid strep test but, instead, proceed directly to treatment. As seen in Table 2, none of the high probability progress note patients received a rapid strep test, whereas 50% of similar template patients underwent rapid strep testing. Moderate likelihood patients should have a strep test performed and, if positive, should receive antibiotics. If the test was not done or was negative, antibiotics were Table 1 Average Counts of Documentation Items, Progress Notes Versus Templates, by Age of Patient TEMPLATES PROGRESS NOTES Patients Patients All Patients Patients All # of <30 30 Patients <30 30 Patients items in: (n=23) (n=27) (n=50) (n=26) (n=20) (n=46) HPI 5.3 5.3 5.3 4.0 4.7 4.3 ROS.8 1.3 1.8 4.2 4.1 4.1 PMFSHx 1.8 1.8 1.8 1.2 1.5 1.4 PE 11.0 10.0 10.5 6.8 7.0 6.9 HPI history of present illness ROS review of systems PMFSHx past medical, family, and social history PE physical examination most likely not indicated. In the current study, comparison of templates to progress notes revealed no significant difference in the frequency of use of the rapid strep test (44.0% versus 34.1%, respectively; P=.319) or use of antibiotics in the absence of an adequate indication (44.0% versus 54.3%, respectively; P=.432). When the template indicated a low likelihood of GABHS, rapid strep testing is not recommended and antibiotics would only be indicated if there was a comorbidity. While in our study sample there were no rapid strep tests run in such patients from either group, significantly fewer low likelihood template patients received antibiotics (10.0% versus 71.4%; P<.05), compared with progress note patients. Table 2 Evaluation and Treatment Decisions, Progress Notes Versus Templates, by Likelihood Estimate of GABHS Disease, Excluding Noninfectious Causes of Pharyngitis TEMPLATES PROGRESS NOTES High Moderate Low High Moderate Low Probability Probability Probability Probability Probability Probability (n=10)* (n=25)** (n=10)*** (n= 4)* (n=35)** (n=7)*** Rapid strep done 50% 44% 0% 0% 31% 0% Antibiotics not indicated (Antibiotics (Antibiotics but given indicated) 44% 10% indicated) 54% 71% Antibiotics indicated (Antibiotics (Antibiotics but not given 10% 0% not indicated) 0% 0% not indicated) * Rapid strep not indicated; antibiotics indicated ** Rapid strep indicated; antibiotics indicated if positive ***Rapid strep not indicated; antibiotics not indicated

520 July-August 2001 Family Medicine Coding Comparing templates to progress notes, there were no statistically significant differences (54.0% versus 34.8%, respectively; P=.059) in overall accuracy of coding (that is, the documentation matched the visit code). Similarly, there was no difference in the amount of undercoding (34.0% versus 41.3%, respectively) or overcoding (10.0% versus 21.7%, respectively). The number of other errors (namely, new patient billed as established patient or established patient billed as new patient) was also similar for both groups. Discussion For patients age 30 and under, this study showed that the templates increased the number of historical items recorded for history of present illness and for past, family, and social history. In addition, more physical examination findings were recorded on the templates for both younger and older patients. Despite the differences in documentation between the template and progress note groups, however, there was no difference in coding accuracy. Because the template facilitated the enumeration of E&M elements and included information on proper assignment of a level of service code, it was expected that it would improve coding accuracy. This was not found to be the case. As an aid in medical decision making, the templates showed some promise. Significantly fewer patients with a low likelihood of GABHS received antibiotics inappropriately. There was no difference in inappropriate testing for GABHS or in the use of first-line antibiotics when comparing the templates to progress notes. While the templates facilitated documentation generally, it is not clear that documenting more items correlates with improved quality of care or better outcomes. Given the complexities of billing compliance, sufficient numbers of history and physical examination items must be recorded to support the level of service being charged. Yet, it is not clear that there is a strong correlation between quality of care and the length of an office note. The two issues, quality of care and billing compliance, are separate and distinct. This template was designed to assist in both, but primarily the latter, and seems to have succeeded in some ways but not in others. The template design limited the amount of space that clinicians had to record review of systems, explaining the higher number of review-of-systems items recorded on the progress notes. This may need to be examined in a revision of the template. The reasons why the template did not improve coding accuracy are not clear. Since the template was designed to be self-explanatory, we did not provide any training to clinicians on how to use the form. A brief workshop or an explanatory instruction sheet may have augmented the template s effectiveness but then it would be difficult to tell whether coding improved because of the template or the educational intervention. A followup study comparing progress notes to templates, with or without additional instruction for both formats of documentation, might be helpful to answer such a question. Reported experience with templates has been mostly positive. Template proformas have been associated with improved informational content in histopathology 9,10 and laboratory reports 11 both in content and quality. In a study by Marill et al, 12 a template-based medical documentation system was introduced in a county hospital emergency department. Physicians preferred the system and generated higher billings, although the system did not save clinical time. In addition to improving documentation, templates can also be used to improve the quality of care according to evidence-based medicine tenets. Panagiotou 13 et al have described an evidence-based well-baby record that was designed to increase the effectiveness of primary care physicians who provide well-child care. While many clinicians may make evidence-based decisions that are supported by the medical literature without written prompts, 14 we attempted to develop a mechanism to make such decisions easier by providing the pertinent clinical prediction rules directly to our busy practitioners. Limitations This study has several limitations. The first is its small sample size, making generalizability difficult. Second, while the single-blind study design helps reduce bias, the auditors performing the conversion of information from the progress notes to a blank template were required to do some subjective interpretation of progress note items to make them fit into the template. Finally, our assessments of the appropriate E&M code that was supported by the note may be subject to interpretation, since audits of notes for E&M coding are often quite subjective. 15 Conclusions Given the challenges associated with the diagnosis and treatment of GABHS 16,17 and the high frequency of this disease, 18 the template-based approach described herein has the potential to improve the quality of medical decisions while reducing costs. Even well-constructed clinical guidelines are unlikely to succeed if they are not readily available to the clinician. 19 Our template was designed to facilitate documentation to improve E&M coding and has the potential to facilitate appropriate decision-making. These are issues important not only to physicians in training but physicians in practice as well. Future study should investigate not only application of this template to a larger number of patients in a variety of settings but also development of similar templates

Special Series: Practice Management in the Residency Setting Vol. 33, No. 7 521 for other conditions, as well as supporting documentation and training in the use of the templates. If further refinements and training improve the performance of templates similar to the one presented in the current study, such templates could be easily incorporated into electronic medical record systems. 20 As the body of evidence-based medicine literature continues to grow, the clinical prediction rules should evolve that can be incorporated into such templates. Acknowledgments: Financial support for this study was received from the Southeast Michigan Academy of Family Practice Research Grants Program. This paper was presented at the March 2000 Wayne State University Department of Family Medicine Research Day Forum in Detroit. We thank Victoria Neale, MD, for her editorial assistance on the manuscript. Corresponding Author: Address correspondence to Dr Rose, Wayne State University, Department of Family Medicine, 15400 West McNichols Drive, Detroit, MI 48235. 313-493-6425. Fax: 313-493-9387. erose@med.wayne.edu. REFERENCES 1. Rose EA, Roth LR, Werner PT, Keshwani A, Vallabhaneni V. Using faculty development to solve a problem of evaluation and management coding: a case study. Acad Med 2000;75:323-30. 2. Cohen JJ, Dickler RM. Auditing the Medicare billing practices of teaching physicians welcome accountability, unfair approach. N Engl J Med 1997;336:1317-20. 3. American Academy of Family Physicians. Pocket guide to the documentation guidelines. Kansas City, Mo: American Academy of Family Physicians, 1998. 4. Moore K. More help with exam documentation. Fam Pract Manag 1997; 4:63-75. 5. Sloane P, Slatt L, Curtis P, Ebell M. Essentials of family medicine. Baltimore: Williams & Wilkins, 1998. 6. Centor R, Witherspoon J, Dalton H, Brody C, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981; 1:239-46. 7. Walsh B, Bookheim W, Johnson R, Tompkins R. Recognition of streptococcal pharyngitis in adults. Arch Intern Med 1975;135:1493-7. 8. Armitage P. Statistical methods in medical research. Oxford, UK: Blackwell Scientific Publications, 1971. 9. Bull AD, Biffin AH, Mella J, et al. Colorectal cancer pathology reporting: a regional audit. J Clin Pathol 1997;50:138-42. 10. Cross SS, Feeley KM, Angel CA. The effect of four interventions on the informational content of histopathology reports of resected colorectal carcinomas. J Clin Pathol 1998;51:481-2. 11. Thilagarajah R, Vale JA, Witherow RO, Walker MM. A clinicopathological approach to cystitis recommendations for simplified pathology reporting. Br J Urol 1997;79:567-71. 12. Marill KA, Gauharou ES, Nelson BK, Peterson MA, Curtis RL, Gonzalez MR. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med 1999;33:500-9. 13. Panagiotou L, Rourke LL, Rourke JT, Wakefield JG, Winfield D. Evidence-based well-baby care. Part 2: Education and advice section of the next generation of the Rourke Baby Record. Can Fam Physician 1998;44:568-72. 14. Michaud G, McGowan JL, van der Jagt R, Wells G, Tugwell P. Are therapeutic decisions supported by evidence from health care research? Arch Intern Med 1998;158:1665-8. 15. Lawler FH, Purvis JR, Paris JA, Horner RD. The effect of faculty private practice experience on appropriate charging for professional services. Fam Med 1990;22(6):487-9. 16. de Silva KS, Gunatunga MW, Perera AJ, Jayamaha DJ. Can group A beta haemolytic streptococcal sore throats be identified clinically? Ceylon Med J 1998;43:196-9. 17. McIsaac WJ, Goel V, Slaughter PM, et al. Reconsidering sore throats. Part I: Problems with current clinical practice [see comments]. Can Fam Physician 1997;43:485-93. 18. Woods WA, Carter CT, Stack M, Connors AF, Jr, Schlager TA. Group A streptococcal pharyngitis in adults 30 to 65 years of age. South Med J 1999;92:491-2. 19. O Connor PJ, Amundson G, Christianson J. Performance failure of an evidence-based upper respiratory infection clinical guideline [see comments]. J Fam Pract 1999;48:690-7. 20. Sujansky WV. The benefits and challenges of an electronic medical record: much more than a word-processed patient chart. West J Med 1998;169:176-83.