Physician-to-Physician Documentation Education

“‘The Brundage Effect’.  The addition of Dr. Brundage to our team at MHS has been truly transformational. Dr. Brundage and his team make clinical documentation simple and fun. The Brundage team has been well received by our hospitalists and internal medicine/FP residents and they frequently seek his expertise real time with documentation challenges. Dr. Brundage is a valuable resource and an expert in navigating the unchartered waters of ACO, BPCI, MACRA/MIPS and value based purchasing.”

-Eric Deppert, MD, FACP, Chief Medical Officer, Manatee Healthcare System

“There is no doubt among our executive team and the physicians at AHSH that your group has done a tremendous job here. You’ve provided invaluable education to our providers in a highly professional manner. CMI up, mortality down, much stronger documentation and a high level of satisfaction among our providers—we couldn’t have asked for anything more.”

Timothy C. Lyons, MD, Chief Medical Officer, St. Helena Hospital 

“Brundage Group has served Riverside Medical Center for several years. Brundage Group provides superior physician advisor services to our organization. They conduct reviews for patient status for our hospital in a timely and professional manner. The reviews serve as both a determination on appropriate status and an educational opportunity for the physicians and the UR team. We have also had Brundage Group on site several times to provider further education for our physicians and providers, to help them navigate the complexities of the rules and regulations around appropriate level of care status and documentation. We work very closely with all members of Brundage Group.”

Carol Kaufmann, RN, BSN, ACMA, Director of Clinical Resource Management, Riverside Medical Center

“I attended a Brundage Group session on medical coding at Sarasota Memorial Hospital.  The presentation was clear, concise and gave great insight into how to better document diagnoses in our medical documentation.  The thought process, and therefore wording, of a medical provider is so different than that of the  “coders”.  So this presentation was very helpful in understanding why wording we use may not be useful in coding optimally for the actual patient condition.  Dr. Brundage gave helpful suggestions regarding how to word notes to clearly communicate the medical side to our colleagues while also providing the information necessary for ICD compliant documentation. I have already started incorporating Dr Brundage’s recommendations into my documentation.”

-Julie Larkin, MD, Infectious Disease Specialist

“Thank you! The doctors really enjoyed your presentation and discussion. It was nothing short of miraculous that so many of our providers showed up that day. I was told many times by many of our people that you handled [them] perfectly! A skilled man indeed!”

-Lori Brand, Administrator, Infectious Disease Associates

“The value that Brundage Group has provided our hospital and our providers has been phenomenal. Our hospital provides excellent care for very sick patients, yet our provider documentation did not always reflect that. Our coding team would help, yet our quality measures—like observed to expected mortality ratio (O/E)—lagged.

The approach of Brundage Group works. The training is physician-led, so the peer-to-peer coaching leads to far more adoption by our providers. Brundage Group drills down on a number of individual providers, leading to giant leaps in the quality of documentation.

Now, in the past six months, our O/E has dropped precipitously, to levels I have not seen since being involved in administration. Our hospital case mix index is much higher, which accurately reflects the acuity of our patients, and vastly helps with our bottom line.

Any hospital or healthcare system looking to improve measures like O/E and CMI, and to improve the sanity of providers dealing with the quality of documentation, should get Brundage Group on board.” 

-Leah Grabenauer, MD, Hospitalist Medicine 

“Thought you would like to know I am seeing an improvement in documentation. More specific and more complete documentation; for instance, including the malnutrition and degree without query, including specificity on the respiratory failure type and acuity without query, pressure ulcers being documented POA, and specificity on diabetes. Great strides!”

-Mimi Jones, BSN, RN, CCDS, Clinical Documentation Specialist, Vibra Healthcare

“I really do feel that Dr. Brundage’s knowledge and familiarity with the proper wording of documentation is very helpful and beneficial for all of us to hear and learn from. I felt it especially beneficial for the surgeons to hear these suggestions from a peer and expert. I felt that Dr. Brundage listened well to the surgeons concerns and complaints and was able to facilitate an open and honest discussion of the best way to document the patients’ need for care. I felt he was very effective in helping the surgeons understand the important role they play in bettering the patients’ experience and the hospital’s ability to be correctly paid for the care they give. I feel the surgeons will be able to better discern what and how they document. The information was much better received from a peer than from an RN. I know they were appreciative of his help.”

-Kamie Gorder, RN, CJR Navigator, Davis Hospital and Medical Center

“Dr. Brundage! Your educational piece with Dr. B (neonatologist) worked! He answered my query for acute respiratory failure and POA, and it was clear your education regarding acute respiratory failure was well received.”

-Jennifer H. Asay, RN, BSN, CDS, Clinical Documentation Specialist, Davis Hospital and Medical Center

“Thank you for the continuous feedback. The improvements that I’ve made in my documentation is reflected in the ongoing coaching and direction I receive from you on a weekly basis. I have made note of the pointers you give during rounds and the handouts provided serve as an excellent reminder/teaching tool for those coding inquiries. I appreciate all you have done and I thank you for your time.”

-Avinaj John DO MA, Intern Physician, Manatee Memorial Hospital

“This was one of the single most important and informative hour updates in a decade!”

– ER Physician

“I just wanted to thank you for your time and attention yesterday in teaching us about documentation and coding.   I wish you could have stayed one more day to hear all the buzz.  I have dieticians, respiratory therapists, liaisons and physicians still discussing your pearls of wisdom.  Your expertise and presentation style will truly make a difference and I could not be more grateful.  I know you are busy imparting your wisdom to another group today but know we will utilize all you left behind.  Thank you again!”

– CEO of an LTAC hospital

“It was a pleasure to meet you and attend your presentation yesterday. I must admit, each and every slide was concise, informational and thought provoking. It will go a long way in improving our clinical documentation. So thank you so much for coming to educate us. I wish we can do this on a yearly basis to refresh our memories and educate newly appointed medical staff.  Again, I want to thank you for organizing this highly informative and educational meeting. You gave a refreshing touch to such a mundane topic.”

-Dheeraj Kamra, MD FACP

“Dr. Brundage’s presentation to our staff kept the room fully engaged. The exceptional value is his ability to speak in the language doctors use to describe disease, while correlating with the language coders seek to verify disease severity and diagnosis. Dr. Brundage invested time beyond his presentation to listen to questions from attendees and answer thoughtfully. Suffice it to say, we will request his services in the future.”

-Regional Chief Medical Officer

“Dr. Brundage: Thank you for meeting with us yesterday. You always manage to answer questions I didn’t even know I had. I have grown quite a bit in my new role, and owe that to my wonderful direction, and to you.”

-Jeri Hazlett, RN, Case Management, Rideout Memorial Hospital

Speaking Engagements

CDI Conundrum Diagnoses, Presented by Dr. Tim Brundage at the American College of Physician Advisors (ACPA) National Physician Advisor Conference

Reviewed by Erica Remer, MD

“Tim Brundage and I have been friends for years, and we co-chair the ACPA CDI Education Subcommittee, but I never had the pleasure of hearing him present until NPAC 2018. The title was “CDI Conundrum Diagnoses,” and Tim masterfully demystified complex topics such as sepsis, heart failure, encephalopathy, and Type 2 myocardial infarction.

He began with and interspersed advice on general clinical documentation integrity. Rather than trying to get providers to internalize the stratification of comorbid conditions and complications (CCs) and major CCs (MCCs), Tim led providers to think of patients as being in three tiers: not sick, moderately ill, or maximally ill. He warned us that providers tend to undervalue their services and their work product. He pointed out that it “takes a licensed medical provider to make diagnoses,” in contradistinction to Dr. Mom who is able to identify symptoms.

Brundage cautioned us that conflicting documentation (“Troponin elevation” in one document, “Type 2 MI from demand ischemia” in another) is “audit candy.” Although I have openly declared war on copy and paste, I actually do agree with Tim’s position that judicious copy and paste with adequate editing is acceptable; indiscriminate and excessive use of the electronic tool by the lazy clinician is intolerable.

The UHDDS Federal Register from July 1985 (p. 123) detailed the definitions of principal and other (secondary) diagnoses. Coders and CDISs often overlook “conditions that coexist at the time of admission,” and Dr. Brundage related that diagnoses in the EMS encounter, the ED, the PCP’s note, and from a lower level of care, like the nursing home transfer sheet, may be utilized, if they are still actively being treated or impacting on the patient’s care during the present encounter. He referred to CMS’ 3-day payment window (72-hour rule), which I understand mandates that outpatient services at hospitals’ wholly owned entities have the technical component of said service bundled into the inpatient admission.

Regarding specific clinical conditions, Tim gave his opinion that providers are too narrow in their application of sepsis under any definition. He feels that patients present later, sicker, and already partially treated, than they used to. He opposes the implication that this is “gaming the system.”

For each clinical condition, a review of words, phrases, findings, and therapy which support the diagnosis and provide “audit protection” was presented. I especially liked his invoking the Framingham criteria for heart failure, and he made the point that this could be quite useful in the case of getting your TAVR into the correct DRG tier.

Similarly, he reminded us that encephalopathy can be bolstered by the liberal use of the Glasgow coma scale where the lowest individual components can serve as MCCs [my 2 cents – this is particularly useful in hepatic encephalopathy, which is only a CC. If your providers follow the mental status deterioration with the GCS, you may be able to capture the MCC, short of coma].

A thorough exploration of the Third Universal Definition of Myocardial Infarction was undertaken, with the caution that they are working on the Fourth Definition (Are you kidding me?!). Pneumonia points included the use of uncertain diagnoses (Why are you giving big-gun antibiotics? Is there likely aspiration?), and to be on the look-out for concomitant acute respiratory failure or sepsis.

After an excellent discussion of many tricky diagnoses, Brundage reminded us of our sacred Hippocratic oath. He reminded us that the words our providers choose, matter.”

“Very nice presentation with great speakers! I also appreciated the examples provided in the webcast; they were commonly seen cases that are not always black and white.”

– Attendee of the RAC Monitor On-Demand Webcast, “Observation or Inpatient: How to Avoid Medical Necessity Denials,” presented by Dr. Brundage and Dr. Patel.

“Dr. Brundage was phenomenal. His info was presented wonderfully and was extremely relevant to our work.”

“Fabulous. Have him again. Wish he had more time.”

– Attendees of the ACDIS Florida Quarterly Conference

Our physician advisors are available to speak to industry professionals on a variety of topics. Contact us to inquire about speaking engagements.