Getting to the Heart of the Office Visit

— Medicare's new coding guidelines are a good start, but we still need to reduce "note bloat"

Last Updated January 16, 2022
A male physician wearing blue rubber gloves types on a laptop and writes on a notepad

Despite remarkable changes to billing requirements that came down the pike in 2021, it feels like not a lot has changed.

For years, people have complained about the onerous burdens required for documentation in charts for E&M (evaluation and management services) coding, which led to endless notes, page after page of not very informative drivel that was included, more often than not, for the sake of up-coding.

To be able to bill at a level that was appropriate for the care we've been providing, doctors have been forced over the past few decades to incorporate huge amounts of extraneous and often not very clinically useful stuff into the notes we were writing. Histories that go on for paragraph after paragraph, when usually just a few words would do. Documentation in the chart that we have reviewed endless amounts of past medical and surgical history, social history, and the like, when in fact that may not have actually happened. I can't tell you how many times I've read "10+ organ systems reviewed in detail and otherwise negative," when more likely the clinical encounter went something like, "Anything else?".

And physical exams -- don't get me started. Cut to the chase; tell me what you examined; we're all smart enough to know that a cardiologist isn't really checking that someone's head is normocephalic and atraumatic. There's really nothing wrong with just putting down what you actually did, because that's what matters.

The new 2021 Medicare coding guidelines removed much of the structure about what components needed to be included and how much detail each item needed to contain. Now the focus was suddenly just on having a medically appropriate history and exam, and the level of service is based mostly on medical decision-making, number of conditions addressed, and total time spent providing the care.

Since these billing and coding changes came along, despite this gift of finally getting what we had been demanding, it feels like we're still suffering from note bloat, that hard-to-resist need to include absolutely everything in absolutely every note. Reading through charts of my patients seen by other providers, and doing internal quality assurance of charts within our own practice, I can see that old habits are very hard to break.

Many of us had hoped, when these changes came about, that we would have started to see a move toward "this is what I asked, this is what I was told, this is what I found, and this is what I think". Changing our notes to reflect this type of thinking, the actual purpose of a clinical progress note -- rather than a collection of templates and click boxes designed by billing and compliance officers -- should really be what we're all about. And it's safe to say that we can really move towards this now, and still be able to bill at the level of complexity for the care we're providing.

Some of my colleagues have gotten really good at this, paring down their notes to the heart of the matter (even if they're not cardiologists): just tell me what I need to know, what it was that you discovered that led you to your plan for this particular patient. Not every single note needs to contain decades of past treatments. I hope as we move into the second year with these new guidelines, we can improve on this, and build ourselves some smarter templates.

It makes me think that there may be ways to harvest data in new ways that might help provide a more comprehensive and truthful record of the actual clinical encounter. Think of this as a body cam for the clinical encounter. Perhaps someday we'll be able to record our history and our physical exam in a way that creates a true electronic record, a version that everyone can share, so all can see the real truth of what took place and what we found.

We're already starting to do this in one way, with digital images that we take with our smart phones and put into the electronic medical record, which have been really powerful new tools to document the extent of a cellulitis, a new concerning mole, or an abnormal gait. Maybe we could think about collecting the data from our stethoscopes, to capture the heart sounds and lung sounds and make them directly a permanent part of the record. Wouldn't it be cool if our entire encounter could be captured electronically and be there for everyone else to see, the actual truth?

Voice recognition software built into the electronic medical record, while it still has a way to go, has made dictation of our thought processes, our assessment and plan, and even order entry, much more seamless and high tech. Perhaps with digital stethoscopes, point-of-care ultrasounds, and high-resolution cameras (think Google glass or police body cams) we could someday create a medical record of each clinical encounter without ever typing a single word. And this technologic data capture could extend beyond the office visit, with more and more clinical data from our patients out in the world beyond recorded and sent back into the system.

Despite using electronic medical records in healthcare for over 25 years, I remain one of the worst typists I've ever met, still hunting and pecking, occasionally forgetting where certain letters are, but I have definitely gotten better and can occasionally even look away from the keyboard and not enter garbage. However, I went into medicine hoping that I was entering a job and a career where I would never need to type.

Maybe we can seize this opportunity given to us, evolve away from being data entry clerks, and get back to doctoring.