Good Morning Colleagues,
Sadly, summer is coming to an end. I hope you all had a great summer and got to travel. I wanted to share something with you all. Recently, one of our very NES physicians in Illinois passed away within 48 hours of finishing her shift. I remember talking to her the morning which she passed. It was a shock to me and her colleagues. This provider was an amazing woman. She frequently worked 36 hours shifts to support herself and her family. She was hard working, compassionate, and a self-less human being. I will miss her dearly. I tell you all this because at NES we strive to be the best. We generally all want the same thing. We desire to be compassionate, we strive to have great documentation, and we hope for the best possible outcomes for all our patients. Just please don’t forget why it is we work this hard. Please give all of your loved ones a big hug and tell them how much you love them. Because in reality, this is all for them.
September’s edition of Lost in TranslatYIN is simple. You all are doing an amazing job improving critical care, documenting EKGs, and smoking cessation. Now, we just want to dot all of our I’s and cross all of our T’s. There are just a couple things that we can do better with as a group.
Many of us use templates to help us chart. I definitely encourage this practice. However, in some of the templates the following phrase is written in regards to labs, EKGs, and imaging: “Interpretation by radiology and independently REVIEWED by me.” I would like you all to change this key phrase to “Interpretation by radiology and independently INTERPRETED by me.” Yes, I agree that I like the word interpretation 🙂. By changing the word “reviewed” to “interpretated”, this adds to the complexity of the patient and the chart. This can be the difference between a level 4 chart (99284) and level 5 chart (99285). Some of you all might think, well I don’t actually interpret the CXR or the CT head. I just read the radiologist report. I would disagree. How many times do you see a CXR that says diffuse infiltrates, could represent edema vs infiltrate. Correlate clinically. Or on a CT AP you read distended loops of bowel with no obvious signs of small bowel obstruction. Correlate clinically. For every EKG, CXR, CT reading that is given to us, it is up to us as clinicians to correlate these images and lab values to what the patient presented with so that we can make a diagnosis. Thus, we are INTERPRETATING our own EKGs, CXRs, labs, and CT scans. For all of your charts, whether you use a template or not, please include the phrase “Labs, imaging, and EKGs were interpreted by radiology and independently interpreted by me.” I am making sure that you all get credit for the hard work that you are already doing.
The second thing that I wanted to go over is the key question that billers and coders look for in our charts. That question is whether or not we considered admitting the patient. In my template that I use in Ohio, I use the phrase “Presenting clinical condition necessitates admission or observation consideration: Yes or No.” I then answer yes or no whether I considered admitting the patient. I do understand I worded this kind of weird. Feel free to come up with your own phrase. It can be as simple as “I considered this patient for observation/admission” or “patient was considered for admission.” This one phrase also adds to the complexity of your chart and can bring a level 4 chart to a level 5 chart. If you do a CT scan on a patient, or did labs on a patient, you definitely considered admitting them. For example, a 77-year-old female tripped and fell and hit her head. You order a CT scan of the head. If that CT showed a subdural hematoma or a skull fracture, that patient would definitely be admitted or transferred right? Thus, we definitely considered them for admission. Another example, a 40-year-old comes to the ED with a simple left leg cellulitis. Patient is afebrile, hemodynamically stable. Patient is not tachycardic. You check a CBC and CMP just because. The patient ends up having a WBC of 20. You admit that patient. Therefore, if you check labs on a patient, you are considering them for admission.
Lastly, please remember in order to correctly document an EKG, we need to include at least 3 of the following categories 1) Rate 2) Rhythm 3) Axis 4) Interval length 5) Q waves 6) ST changes 7) T waves 8) Heart blocks 9) Comparison to prior EKGs. A couple examples are “EKG shows NSR with HR 80, normal axis, prolonged QTc at 480, no ST changes” or “EKG shows Afib with RVR with HR 130, right axis, Q waves in inferior leads, no ST changes.”
Thank you all again very much for listening. Your dedication to documentation and to our patients is what makes NES special.
Humbly yours,
David Yin
