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The department of psychiatry has been having ~30% of its bills down-coded because of missing elements in documentation. Review of down-coded documents revealed that the history of present illness (HPI), review of systems (ROS), and mental status exam(MSE) were the most common areas resulting in down-coding. Leadership in the department tasked the department’s quality improvement (QI) leaders to find a solution to the issue.


Department QI leaders established a committee that comprised of department leadership, billing and coding, compliance, trainees, and faculty. After multiple meetings, the issue of what was being downcoded was deciphered and a plan to create autotext templates for use by providers was undertaken. After construction of the autotext templates, the committee reviewed the autotext templates for editing and then submitted the new templates for building in the electronic medical record (EMR).


Autotext templates for; HPI, ROS, MSE, and medical decision making have been built into the EMR for use by providers. Members of the department QI committee are planning the implementation of the changes in the EMR and a strategy for the widespread implementation has been decided upon. Tip sheets and provider trainings are scheduled to occur in early 2020. Afterwards, department leadership will compare previous and post project down-coding rates and improvements in lost revenue.


Presented at the University of New Mexico Health Science 2020 Annual Quality Improvement and Patient Safety Symposium



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