Episode 36 – April 2022: Coding Tips & Medical Education

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, a lightly-breaded monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: In our Sizzle segment this month, we'll learn what Maine Medical Center's Department of Medical Education has to offer providers, both those at Maine Medical Center and elsewhere.

Mike: But first, we get a few clinical documentation tips from a primary care doc who's become a master of diagnosis coding.

Julie: All right. Let's get to it.

Mike: Value-based care agreements rely heavily on accurate and precise clinical documentation to be successful. That's because cost and quality goals are at the core of these agreements, and they're set based in part on how sick patients are. So, if patients appear healthier than they really are, these goals become harder to reach.

Julie: That's right. And to add even more urgency to accurate clinical documentation, more and more value-based contracts include downside risk, which is basically a financial penalty levied when goals are missed.

Mike: So, in the cause of better documentation, because of this, we thought it would be a good idea to provide some diagnosis. Coding tips from a real primary care doc who's learned to do a pretty good job in this area.

Julie: Yes, our producer, Paul Santomenna takes it from here.

Paul: I'm joined now by Dr. Sam Ferguson who's an internal medicine physician at western Maine Primary Care, who was recommended to us as someone who's doing a good job on clinical documentation. So, Sam, can you just give us a little bit of background on your practice there in Norway?

Sam: Yeah. So I'm an outpatient internist in Norway, Maine; office associated with Stevens Memorial Hospital. We service the catchment area of western Maine and parts of New Hampshire, basically. So pretty wide patient demographics, seeing a lot of folks from all walks of life up here, but kind of service an older, more complicated patient population as a result of the folks who live in western Maine.

Paul: You've had quite a bit of success figuring out HCC coding and getting accurate RAF scores for your patients. Did this just come to you naturally or did you make a concerted effort to kind of get good at this?

Sam: I think, for me, I had the advantage of training with the EMR just because it's something that's been part of medical education really my entire career. So I think just by virtue of being more familiar with where things are in our particular EMR as well as kind of how to code for things, has helped a lot. And then also a lot of it really has just been learning kind of appropriate use for coding. So, really, what falls under something that's CMS required of reporting and looking for HCC codes and things like that. Really, a lot of it is just kind of knowing where things are and recognizing when you should appropriately be looking into things more or recognizing that it's something you should be more aware of. Depending on your EMR, so in our case, Epic, really kind of understanding how the BPA or the Best Practice Advisories work. And you know, a lot of the time when we have an EMR, we're always worried that there are too many things flashing and sometimes you get fatigued as far as knowing what's important, what's not important. But the HCC gaps are pretty well highlighted and a lot of the time is just realizing that that's something that you can use to help guide both your coding as well as making sure that you're appropriately coding patients or how complex they are. So a lot of it's just kind of recognizing where that is. So in Epic, it would be you see it in every patient visit if there are specific gaps. And then a lot of the time in your problem list, kind of knowing that if you have something that's a really generic problem, that there's potentially a better way to code for it, that better captures how complex that patient is, and sometimes that just takes a little bit of knowing how changing diagnoses or coding in general works in your particular practice.

Paul: Have you had much support from your sort of practice care team around this? It seems like this could be a heavy lift for a single provider.

Sam: Yeah. So our group together made a pretty concerted effort to really focus on HCC coding and appropriately capturing just how complex our patients are. So it really did involve just more than the doctors here and involved our support staff as well as some of our clinical nurses and MAs who are helping us with making sure that we are capturing correct HCC codes when we were coding folks. So it really took both the doctors recognizing it and appropriately updating things, but at the same time, a multidisciplinary approach to make sure that we were looking for things that we either missed or we're appropriately getting everything else at.

Paul: So it certainly helps to have a whole team behind you, it sounds like.

Sam: Yeah.

Paul: If you could identify maybe one thing, a single thing that a provider could do to improve their clinical documentation, is there something you could point out?

Sam: I think the thing that I would say is if you're coding for really generic things like, say, you have a patient with obstructive lung disease and you're just putting in obstructive lung disease, it's sometimes worthwhile to be more specific, and you would be surprised at times how often you'll either find that you should be coding for an HCC code based on this specific diagnosis. For example, like COPD or emphysema might come up with an HCC code that's more appropriate for the patient. And then some other things as well, so things like obesity, if someone is working on treating obesity and you realize that they have other high-risk features, that does change exactly how they're coded. So you might be missing some things if you're not being specific enough with the problems that you're putting into Epic or your EMR.

Paul: Right. Right. Any other sort of tips or tricks that you could share in your experience?

Sam: Yeah. So I think some of the other things that I've noticed, too, is making sure that you're — it does require a little bit of time because you really do want to know your patients and appropriately code them, so I've actually seen the opposite happen every once in a while where something will come up as an HCC gap when in reality it doesn't apply to that patient. So just kind of knowing the clinical gestalt of who you're taking care of and if you're accurately capturing how complex they are or if this is just something that's living in the chart and may not necessarily be anything you're following up on. It's definitely more work on the front end to make sure that you're updating things that are potential HCC gaps or potential HCC coding problems. But you know, once you kind of know and recognize them and then also know where to find things in your EMR, so for example, if you have, there is a BPA that comes up, if you have gaps you haven't closed, if you know where that is and kind of how to go through it appropriately, that can just help you a lot right there. The honest truth is a lot of Epic really does kind of pay attention to those gaps. And it does remind you if you haven't addressed something for a while, so whenever I see a patient, I always double-check and see if there are any gaps that I missed or, you know, things that aren't being followed up on just to make sure that we either were capturing that. And then a lot of the time, honestly, clinically, it helps as well because it's something I care about that I've been following. I generally use the annual wellness visit or the annual physical as kind of the best time to really make sure that everything is accurately reflecting things. But like, say, you know, if I do have six months follow-ups or someone who is following up for a problem that may potentially be an HCC gap, I may be addressing it at that visit specifically, but I do usually try to use my annuals or annual wellness visit to really make sure that we've done everything, at least within the past calendar year, to accurately reflect what we're treating and managing.

Paul: Great. Well, thanks, Sam. Thanks for taking a few minutes out of your day to talk to us about the thrilling topic of coding.

Sam: Super fun, yeah. The honest, I mean, the honest truth is just kind of, you know, knowing where everything is and doing everything very similarly and make sure that you kind of keep it as a habit, because if you stay on top of it, it's a lot easier than trying to play catch up.

Paul: Thanks so much.

Sam: Absolutely.

Mike: For our Sizzle segment this month, we welcome Dr. Bob Bing You and Dr. Leah Mallory to our virtual studio. They're going to share what's going on in the world of medical education at MMC. Welcome.

Bob: Thank you for having us.

Julie: Well, thank you for joining us. So for those who don't know, tell us a little bit about yourself and what the function of the Department of Medical Education is.

Bob: Sure, I'll start. Again, my name is Bob Bing You. I've been a long-timer at Maine Medical Center. 36 plus years. I did my internal medicine, training and endocrinology fellowship. Most recently, I was the vice president of our medical education, and currently, I'm the director of continuing interprofessional development. So the Department of Medical Education is part of the Division of Academic Affairs, which also includes the MaineHealth Research Institute and the Innovation Center. So, our goal of the department is to really support the academic mission. And one of the missions is to educate tomorrow's caregivers. And so we support learners throughout the medical education continuum. We currently work with over 750 medical students and residents and fellow trainees, and that includes the main track, which is our fantastic partnership with Tufts. And we also support over 2000 physicians and interprofessional faculty throughout the state. We often say the state of Maine is our campus, and I'll let Dr. Mallory introduce herself and also talk about the simulation center.

Leah: Thanks, Bob. I'm Leah Mallory. Clinically, I'm a pediatric hospitalist, and I've worked at the Barbara Bush Children's Hospital for about 15 years now. I did my medical school training in California in the Stanford system, where David Gaba founded a health care simulation. So just like airline pilots use fancy simulators to practice for emergencies, you know, orchestras practice, in health care, we too need to practice. And so simulation, both using high fidelity mannequins, which are quite sophisticated, mocking up rooms to look like operating rooms or trauma rooms, but also using simulated patients or standardized patients to practice communication and physical exam skills is part of medical simulation. So 11 years ago, Maine Medical Center built the Hannaford Center for Safety, Innovation and Simulation. It's a very well-resourced, beautiful center over at the Brighton campus, but we also have a simulation van and with unification now we are a resource for MaineHealth and can go all over the system to bring simulation to various locations in MaineHealth. So, about half of what we do is training and education focused on our graduate medical education learners, our medical students. More and more we're servicing interprofessional learners and also practicing faculty, and then we also do safety training. So we do team training in native clinical environments. We can test systems or new facilities and do a patient safety analysis before we actually move patients into those spaces or try to do those services with them. So I've been the medical director of the Simulation Center for three years now, and I love my job.

Mike: Wow, the department covers a lot of territory, so in the midst of all of these different initiatives, what are you most excited about right now?

Bob: Yeah. I would say one of the most exciting things is our increased focus on interprofessional learning and education through accreditation. So most recently at MaineHealth, we received what's called joint accreditation. So prior to that, a practicing clinician in any profession had to go through their own professional society. So, nurses had to get accredited through a nursing organization. Physicians had to go through the Accreditation Council for CME. But with joint accreditation now, all learners sitting in the audience can receive the same credit for attending that activity or participating in that educational opportunity. So that just happened about a year ago, and we're starting to spread that joint accreditation throughout the health care system. And the focus, again, is on interprofessional education. And the mantra is education by the team, for the team, really focused on interprofessional and team-based learning. I think another exciting thing about learning is, with the challenges, the pandemic aside, the pandemic has really helped us focus on more distant remote learning through mechanisms like Zoom and online learning. And that really has helped us spread our opportunities throughout the health care system. Leah, do you want to talk about simulation?

Leah: Sure, it's hard to choose two things I'm most excited about, but I will say in line with what Bob was talking about, I'm quite excited about the interprofessional team training opportunities across the system as the health care system thinks about how to use our resources wisely, how to optimize our regional centers to offload overloaded areas at Maine Medical Center to the benefit of both sides of the system. You know, teams in regional places can absorb new programs or leverage telehealth to keep more patients in their communities and in their hospitals. Simulation is a powerful resource to enable those things to happen. Just Monday, we will go to North Conway and we'll do some obstetrical team training. So that is for some of our smaller hospitals with lower birthing volumes. Emergencies, fortunately, are very, very rare, and yet you need to stay prepared for them in order to deliver babies safely. So simulation is perfect for that. So we will start going around the Maine Health System and doing an obstetrical emergency training with teams in their delivery rooms. So the first ones Monday in North Conway. The other thing I'm very excited about are opportunities for our standardized patient program as we explore things like diversity, equity and inclusion and how to provide more equitable health care to people, that requires training. Those of us who've been doing this for a while need to learn new languages. We need to learn how to ask difficult questions and how to do things better than we learned how to do them. And so we're developing curriculum, looking at gender-informed health care, how to better provide that and how to increase equity in health care. That's pretty exciting. We're also looking at the problem of workplace violence and behavioral emergencies and how to use verbal skills to de-escalate patients to prevent physical harm from happening for our health care providers, that's a bit of an epidemic, and simulation is a perfect resource to address that problem. So that allows me to sit in a room with people from behavioral health and psychiatry, security, patient safety, patient relations, and sort of leverage their expertise to utilize our resource to achieve objectives for the system. And that is super exciting.

Julie: So what resources are available to providers that are outside of MaineHealth?

Bob: Yeah. I think we have many resources available to practicing clinicians outside of MaineHealth and also within the system. I would just highlight two opportunities. One is the Maine Medical Center Institute for Teaching Excellence called MITE, M I T E. And I think through this podcast or on the BACON website, there'll be some links for you to access the MITE website. And on the MITE website really is to support what we call faculty development. So there are online courses, there are public courses available, there are teaching seminars. And so there's a whole host of resources for faculty instruction in education. And the second thing I would highlight is the recent development with Grand Rounds. So, I've been in this business long enough to know that many people for years have wanted to have access to grand rounds that were happening at Maine Medical Center. So most recently, we are piloting six different departments to provide easy access to access those grand rounds that happen on a weekly or monthly basis. And those six departments are psychiatry, pharmacy, internal medicine, cardiac services, OBGYN and pediatrics. So anybody in the state or actually outside the state can access these grand rounds easily by going to the website and registering for those particular grand rounds.

Mike: Thank you. Those are fabulous resources and sounds like there's some great opportunities for people both within and outside the system to get involved in medical education. Any other thoughts or opportunities you'd like to highlight as we conclude our interview?

Bob: Well, I think being a faculty or involved in teaching our tomorrow's health care givers is a fantastic way to be involved. We sometimes say academics or teaching is the anecdote for burnout. So being faculty or working with learners is, I think, a fantastic way to get some professional reward. And people do find it professionally rewarding to work with learners. And it's a great way to again, establish some long-term relationships with our learners who often end up practicing back in the state.

Leah: And I would say for simulation we offer an annual simulation instructor course. That's a two-and-a-half-day course here at the Simulation Center that focuses on using simulation as a training tool and also how to facilitate really effective debriefing. Because we always say for simulation, the simulation itself is just an excuse to debrief, which is where you really consolidate information, share perspectives if you're doing interprofessional simulation. And that's a very fruitful two and a half days, quite low cost and open to anyone. It's not specific to MaineHealth. So, anyone who's interested can contact the SIM center and hear when that's going to happen. And we're looking forward to offering some more advanced workshops, looking at things like advanced level debriefing or doing simulation-based clinical systems testing, testing those new protocols or spaces before you bring patients into them. So look at our website for opportunities that are open to all.

Julie: Well, thank you very much both for joining us. This has been enormously informative. I really appreciate your time and what you've shared with us. Thank you.

Leah: Thank you.

Bob: Thanks again for having us.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments and suggestions, we really would love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Julie: BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next month.

Mike: See you next month.