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Watch Your P’s and Q’s: Coding and Documentation Presented by: Georgette Gustin, CPC, CCS-P, CHC PricewaterhouseCoopers HCCA Compliance Institute New Orleans - April 28, 2003 Watch or Mind Your P’s and Q’s…. 50 year-old meaning Described as “to mind one’s manners” and “to behave properly” “The careful exact or prudent behavior” “Just mind your please and thank-you’s” Incorporating concept into coding and compliance issues through ¾ Behavior; and ¾ Communications. 2 Today’s Discussion Relationships Coder/Physician Communication Types of Communication ¾ Communication Styles Matter Common Reactions ¾ Tips for Dealing with with Coding and Documentation Issues ¾ Communicating Coding and Documentation Issues Helpful Hints ¾ Word Selection Tips Tricks of the Trade 3 Relationships Dependent upon the senders role and needs, the relationship and communication process will differ ¾ Coder or Compliance Analyst/Auditor ¾ Educator/Trainer ¾ Compliance Officer ¾ Administrator ¾ Business Office ¾ Chief/Department Chair ¾ Utilization Review/Case Managers ¾ Health Information Management (HIM) Department 4 Coder/Physician Communication Finding and establishing the communication link is critical to: ¾ Documentation ¾ Compliance ¾ Reimbursement Recognize the language differences ¾ Clinical ¾ Technical Establish processes to overcome barriers ¾ Develop the appropriate approach ¾ Build Trust ¾ Facilitate access ¾ Provide tools/resources ¾ Establish routine/schedule ¾ Implement feedback and monitoring processes 5 Types of Communication Verbal ¾ Orders/Instructions ¾ Voicemail ¾ Education Written ¾ Documentation – Memo’s – E-mail – Policies/Procedures – Medical Records – Physician Orders – Prescriptions 6 Communication Communication requires: ¾ Sender ¾ Receiver Communication can be: ¾ Misunderstood ¾ Misinterpreted ¾ Omitted ¾ Corrected Communication can: ¾ Determine outcomes ¾ Improve teamwork ¾ Impact results ¾ Create lasting images ¾ Impact Patient Safety ¾ Impact Coding & Compliance 7 Communication Style Matters How do you communicate with your physicians or others on coding and documentation related matters? “Let me Hear your Body Talk” “Words can’t Bring me Down” “Killing me Softly with his Song” 8 Common Reactions: Coding/Documentation Issues “No one is going to tell me what I can code.” I did the work, it’s my money!” “I just want to take care of my patient’s, this is all red-tape that frankly I don’t have time to deal with” “This is not my problem its yours, I need to take care of patients” “The rules are complex and burdensome and are no benefit to me or to my patients” “I understand why we have to do this, just help me to streamline the process” 9 Tips for Dealing with Coding/Documentation Issues Develop a Mantra: “Think before you Speak” Understand and anticipate what stage you might be dealing with: ¾ Denial ¾ Anger ¾ Bargaining ¾ Depression ¾ Acceptance Be prepared, don’t waste time, be specific & get to the point 10 Communicating: Coding/Documentation Issues Avoid Negative Body Language Submissive, closed and defensive Aggressive, closed and attacking ¾ Wobbly voice ¾ Hard voice ¾ Slow speech ¾ Rapid speech ¾ Worried expression ¾ Extremes of expression ¾ Evasive look-downs ¾ Excessive/no eye contact ¾ Defensive arms/legs ¾ Dominate posture ¾ Mouth covered with hand ¾ Finger jabbing/wagging ¾ Excessive distance ¾ Invasion of personal space 11 Helpful Hints Select your words carefully and really listen (empathetically) Most important words in our language ¾ 6 words: “I admit I made a mistake.” ¾ 5 words: “You did a good job.” ¾ 4 words: “What is your opinion?” ¾ 3 words: “Let’s work together.” ¾ 2 words: “Thank you” ¾ 1 word: “We.” Be sure you are speaking the same “language” Employ some of Stephen R. Covey’s… ¾ “The Seven Habits of Highly Effective People”: – – – – – – – Seek first to understand before you can be understood Think “Win-Win” Begin with the End in Mind Be Proactive Synergize Put first things first Sharpen the Saw 12 Word Selection Tips Word Selection: Negative vs. Positive Positive Comments Negative Comments ¾ Perhaps I haven’t explained myself ¾ You don’t understand ¾ It isn’t my fault ¾ We’ve always done it this way ¾ To resolve it we need to… ¾ How should I know…they never tell me anything around here ¾ How would you like to see it done? ¾ I’ll find out ¾ I just don’t have enough time ¾ I need to prioritize my tasks and do the most important ones first 13 Tricks of the Trade Build a partnership Be patient, reasonable and consistent Persevere Keep a Positive Mental Attitude Set goals Reward and recognize positive change Demonstrate value Share Best Practices Never preach or be condescending 14 Questions & Answers Georgette Gustin, CPC, CCS-P, CHC, Director Healthcare Consulting Practice (317) 860-2131 e-mail: [email protected] The vessel is a symbol for people from many different worlds working together and sharing knowledge. 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