Documenting Medical Decision-Making: The Indispensability

Medical decision-making (MDM) is arguably the most important part of patient care.  Materializing from a clinician’s experience, knowledge, and judgement, MDM involves high stakes and is formulated in the best interest of patients.  Physicians consider a wide range of perspectives, preferences, values, and needs while arriving at a plan that is in line with patient autonomy.  Evolving payer policies and recent shifts in reimbursement models demand accurate MDM documentation to validate the level of visit as well as ensure correct levels of coding and reporting.  New-age provider engagement solutions such as RevCDI-led coding from Reventics leverage platforms powered by AI to improve MDM documentation, enhancing compliance and revenue. 

Documenting MDM: 

MDM requires high level of probabilistic reasoning as it involves significant variation in risk and outcome preferences among patients, providers, and payers.  Physicians are expected to have a thorough understanding of the underlying disease processes and most up-to-date treatment options.  Physicians must also consider problems that are primarily being managed by other physicians while formulating the management plan.  MDM is often based on small volumes of data that are either conflicting or of uncertain validity and reliability.  With individual health outcomes being probabilistic, medical decisions are complicated, more so when they are made in the face of uncertainty.  While what physicians do for a patient may often seem simple, what are they actually thinking? What complex medical decisions are evaluated in their brains and are they getting it down on paper accurately? 

Although physicians can confidently establish the acuity and severity of a problem, the nature of presenting problem, patient's condition, any supplementary data reviewed as well as corresponding plan of care must be documented for each visit, not just for reimbursement, but to let the next physician know what they were thinking as they compiled the objective and subjective evidence.  Detailed notes defining the reasons for considering a particular diagnosis/treatment over other possible diagnoses/treatments must be recorded.  While the patient's condition or problems may not change dramatically during a given day of hospitalization, physicians must record all changes and services provided at each visit with service dates to establish the complexity of a case during medical record audits.  Deficient documentation may fail to corroborate appropriate management of a particular problem, diagnosis, testing, or treatment strategy, downgrading the apparent complexity of the visit and reducing RVUs.  The administrative burden of paperwork associated with documentation often overwhelms physicians, takes time away from patients, and can subsequently lead to burnout. 

The launch of “Patients over Paperwork” initiative allows physicians to select E&M services based on total time spent on the day of the visit or the level of MDM.  This makes MDM one of the key factors in defining the level of service.  The new guidelines require physicians to be more detail-oriented while documenting MDM rather than wasting time on noncontributory “mandatory H&P elements.”  They ideally should describe the management of a diagnosis as opposed to just selecting the diagnosis.  The complexity of the visit is stratified based on the number and nature of clinical problems, amount and complexity of data reviewed, and risk of morbidity and mortality of the problem and the treatment.  For example, physicians must record the number of diagnoses and/or management options they must consider as well as the amount and/or complexity of medical records, diagnostic tests, and/or other data they must obtain, review, and analyze. 

Physicians must capture all crucial elements of the visit: 

• Either the date of visit and total time spent including non-face-to-face work done on same day or the MDM, and no longer the percentage of time spent counseling/coordinating care. 
• Nature of service if it is ordered, planned, scheduled, or performed at the time of visit.
• Any decision to obtain outside records or additional information from patient's family, caregiver, or other sources. 
• Discussion of results of each individual lab/radiology/diagnostic tests and if discussed with the physician who performed or interpreted the studies. 
• Discussion of management with another person or surrogate decision maker.
• A diagnosis, assessment, or clinical impression that may be explicitly stated or implied for management plans and further evaluation.  Alternatively, “differential diagnosis”, “possible”, “probable”, or “rule-out” if a diagnosis is not established.
• Document every problem with a diagnosis, and also if the problem is well-controlled, resolving, resolved, or having an exacerbation, progression, or side effect.

Clinical Documentation Improvement for MDM: 

The intensity of cognitive labor performed can only be validated through comprehensive physician documentation.  When it comes to documenting MDM, every problem or diagnosis addressed should be documented with a plan of care and the thought processes surrounding the decision.  Employing clinically focused and technology-driven RevCDI-led coding significantly eases the administrative burden of tedious MDM documentation.  RevCDI uses advanced NLP and ML platforms to scan through charts and provide near real-time, actionable, individual chart specific CDI feedback to improve MDM documentation.  The alerts and tips are non-intrusive and focus on driving compliance and improving revenue.  RevCDI also provides physicians with performance reporting on compliance, customized education materials, and comparative dashboards on deficiency levels in a simple and meaningful way.