This toolkit helps you reduce your documentation and coding workload by:
- Describe the latest billing and encryption documentation guidelines
- Illustrate workflow solutions for more efficient documentation
- Providing sample documentation to help educate physicians and their teams
Physicians and support team members in medical practices are struggling with burnout at an unsustainable pace. An unmanageable workload, largely due to the electronic patient record (EHR) documentation burden, contributes to physician burnout. In addition, a doctor sitting in front of a computer and the administrative task of data entry and note-taking is a low-value use of a high-dollar resource.
Doctors and advocacy groups have been calling for a reduction in legal requirements for less meaningful work over the past decade. In recent years, there have been 2 major beneficial regulatory changes to reduce the documentation burden and redundancy for physicians during outpatient visits:
- January 1, 2019 (PDF): Allow support staff to document certain portions of the clinical note for physicians to review and verify, rather than independently re-document1
- January 1, 2021: Changing the Service Level Codes (LOS) to depend only on medical decision making or time, not on history or physical examination elements2
These changes recognized duplication in data collection and recording, helped clarify billing rules, and removed specialty-specific challenges created by the previous guidelines that had been in use for a quarter of a century. While it may have seemed intimidating to many physicians to understand one more set of rules, most practicing clinicians agree that these changes “made sense” and made their lives easier because substantial requirements were not added and many requirements were removed.
Learn how to optimize documentation and coding strategies in just 4 STEPS with the complete toolkit PDF.
Clinical Vignette Pack
Use this pack (PDF) of all 5 clinical vignettes from the STEPS Forward® toolkit for simplified documentation and coding during personal training sessions.
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