In 2021, the Centers for Medicare and Medicaid Services (CMS) implemented new regulations, designed to reduce the administrative documentation burden associated with evaluation and management (E/M) Current Procedural Terminology (CPT) billing codes. The revisions to the code descriptors and documentation standards directly address the continuing problem of administrative burden for physicians in nearly every specialty. The changes are intended to move documentation for E/M office visits to center around how physicians think and take care of patients, instead of on mandatory standards that encourage copy/paste and checking boxes.
As such, a medically appropriate history and/or a physical examination are no longer required to select the level of service. These portions of documentation historically have added considerable “fluff” to clinical notes. However, now that these elements are not required, clinicians can alter their documentation templates to include simplified, pertinent information only.
These new regulations appeared to be a godsend to providers who have historically struggled to meet time-consuming clinical documentation requirements that were published back in the 1990s.
“I thought they were the greatest thing to ever happen to physician documentation,” says Sam Butler, MD, a physician who works for Epic, an electronic health record (EHR) company in Verona, WI.
Butler’s initial enthusiasm, however, was tempered when he and a team of researchers conducted a study to determine if the legislative changes had the desired effect on clinical notes. The team evaluated 1.7 billion clinical notes written by 166,318 outpatient providers in Epic EHRs in the United States from May 2020 to April 2023 to determine the average length in characters for each note. The research found that the average note length across all clinical notes had increased 8.1 percent, from 4,628 characters in May 2020 to 5,002 characters in April 2023 – the exact opposite of the new regulation’s intent.
The study, released in July, did find that the time required to create these notes was reduced. Despite the increases in note length, the average time spent writing notes decreased 11.1 percent over the same period, from an average of 5.4 minutes per note to 4.8 minutes per note. Additionally, providers are spending less time in clinical review activities in the EHR.
Butler, however, suspects that might have just been a fluke. The time spent creating notes varies quite a bit – and researchers just happened to study a period when providers were more quickly completing their documentation, he says.
The longer notes add significant burden to the workload of health information professionals, specifically clinical documentation improvement (CDI) staff members, according to Lisa Boyer, RHIT, CPMA, director of compliance at Elevate Medical Solutions, a medical coding consulting company based in Madison, WI. More specifically, excessive documentation reduces a coder’s productivity and effectiveness; increases the opportunity for coders to erroneously capture contradictory and/or outdated information; and boosts the potential to overlook important, reportable diagnoses codes as key information might get buried in the note, Boyer notes.
Why Are There Long Notes?
The study’s findings have prompted Butler and other industry leaders to ask the next logical question: Why haven’t the new regulations resulted in shorter clinical documentation as intended?
Butler suspects that physicians are still writing long clinical notes because they are adhering to the guidelines that were issued in 1995 and 1997 that required clinicians to provide extensive documentation to get paid by insurers.
“We did a great job of educating this generation of physicians that long notes were essential to get the maximum pay,” Butler says. “One thing physicians learned quickly was that if they just wrote the long note, that would give them the best chance of getting paid more. If physicians went short, though, they risked not getting paid.”
He says many physicians might still be leery of adopting the newer 2021 regulations, as they suspect that payers are simply not going to accept the new, shorter notes. As such, they may be erring on the safe side and sticking with the more complex clinical documentation.
Boyer agreed that many physicians are continuing to cover their bases with the longer, extensive documentation. She adds that technology is facilitating this practice.
“Some of the [EHRs] are the culprit because they are making it easy to pull forward documentation,” Boyer says. She contends that many EHRs make it easy to pull comprehensive documentation forward, but don’t make it easy to pull specific information such as a chief complaint into a new clinical note. These longer notes present a challenge for HI professionals and coders, as they often spend an inordinate amount of time reading superfluous information.
How to Keep Notes Brief
According to experts, physicians are more apt to adopt shorter documentation if they:
Receive more education on the new rules. “Education and more education, that’s what’s needed,” Butler says. “Continued education from the American Medical Association and specialty societies such as the American College of Physicians is needed to convince physicians that the longer documentation is no longer necessary. And also, it falls to better education from the EHR companies like Epic to continue to educate physicians that they don't need to write these long notes. The most important thing is to get the word out to the physicians...not only are they going to have to believe it, that they're going to have to do it and see a few months go by where they're still getting paid the same.”
Take advantage of new technology features. EHR vendors are adding new features designed to reduce note bloat. For example, Epic is adding a feature that will create a citation that links to a patient’s medical history instead of adding the information in its entirety to the note. “So if somebody wants to read it, they can click and instantly go to it, but it doesn't have to take up room in the note,” Butler says.
In addition, medical staff can work closely with health information professionals to come up with a plan that outlines how to produce effective, concise clinical documentation within the healthcare organization’s EHR, Boyer noted.
Consider revisiting documentation models. “My recommendation to some of the providers we work with is to go back to the SOAP note, or the subjective, objective, assessment and plan, which goes back to the ’80s when physicians started dictating their notes by following that format and most often it covered problem-specific information,” Boyer says. “They didn't pull in the fact that they had a cataract surgery done on the left eye in 1980 and the right in 1992 when a patient came in for an abdominal pain visit.”
Some healthcare organizations have also adopted SOAP 2.0 — succinct/specific, original (no plagiarism), accurate, and problem-oriented.
The APSO (Assessment, Plan, Subjective, Objective) format, which, in essence, is an inverted SOAP note, is emerging as another potential documentation alternative. In fact, a study published in 2017 in the American Journal of Accountable Care determined that clinicians using APSO found it “easier to find clinically relevant data,” “easier to follow clinical reasoning,” and “faster to browse through APSO notes.”
Work with team members to update documentation. “Providers need to work with their health information team or their nursing staff to come in and find a way to update the problem list, the past family social history, the medication lists. There are so many of those historical documents that are out of date and do not provide information pertinent to the visits,” Boyer says.
Impose limits on documentation formats within healthcare organizations. “If you have a hundred doctors, sometimes you get a hundred different techniques of documentation, but each organization should have only one to three uniform documentation formats,” Boyer says. “That makes it easier for providers to provide the right level of documentation.”
John McCormack is a Riverside, IL-based freelance writer covering healthcare information technology, policy, and clinical care issues.
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